Why wouldn’t you want an EKG every year as part of your check up? Why would you not want to be screened for prostate cancer at the age of 80 (or maybe at any age)? Why should you decline the annual chest X ray that your doctor keeps ordering? Is it because you’re eager to save money for your insurance company? Is it because you think going without the test will help others who are more needy get the test in some complex rationing scheme? No. You should forego the above tests because they are much more likely to harm than help you.
Unfortunately, some of the care physicians deliver is entirely without benefit. I’m not saying merely that some care hasn’t been proven to be effective. That can be excused, since in many fields the scientific evidence is scant and the individual doctor’s judgment is our only guide. I’m saying that much of the care that is delivered has been rigorously proven to be ineffective or harmful.
Why are doctors ordering so many useless tests and treatments? Some blame “defensive medicine” the practice of ordering tests or treatments not for the patient’s benefit but to protect the physician from liability. Some blame unsophisticated or demanding patients. Neither of these explanations is fully persuasive.
Whatever the cause of this pervasive delivery of care that is worthless or worse, a group of American physician specialty societies have partnered with the American Board of Internal Medicine Foundation to do something about it. Their initiative, Choosing Wisely, lists 45 tests and treatments in nine different specialties that physicians should stop ordering and informed patients should decline. These tests and therapies have been definitively found to have no value and yet remain widely utilized.
Some of the 45 recommendations of Choosing Wisely are:
- Don’t order sinus CT or prescribe antibiotics for uncomplicated acute rhinosinusitis.
- Don’t screen for osteoporosis women younger than 65 or men younger than 70 with no risk factors.
- Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
- Don’t repeat a colonoscopy for colon cancer screening sooner than 10 years after a normal screening colonoscopy.
- Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
I strongly encourage you to explore the website and read the recommendations yourself.
Of course, physicians who have been trained recently or who keep abreast of the medical literature already know most of these recommendations, and patients going to doctors who practice evidence-based medicine have already been taught many of them.
But if these treatments and tests are known not to help patients, why are they still performed so frequently? The “defensive medicine” excuse rings false. After all, the best legal defense is ordering what’s best for the patient. Some use of ineffective tests and treatments could be attributed to ignorant and demanding patients, but where would the patients initially have learned to ask for an annual EKG or an annual chest X ray if their prior doctor had not been ordering these tests?
I think the only convincing explanation for the misuse of most of these tests and treatments is economic. Doctors make much more money in ordering these tests than in educating patients that they’re bad for them. Moreover, the patients don’t suffer the economic consequences of this misuse, since the cost is frequently borne by insurance. Our broken healthcare system insulates patients from the costs of their healthcare decisions and thereby encourages the use of expensive therapies that have little value. In other marketplaces, in electronics, or transportation, or clothing, or food, expensive goods that have little value are usually called rip-offs. A few unsuspecting customers might fall for them, but word soon spreads and consumers soon learn to watch their wallets. But in healthcare the patient isn’t paying, so he doesn’t bear the price of the rip-off but redistributes it to the other enrollees of his insurance company (or to taxpayers if he has Medicare or MediCal). The insurance company can then try to limit the utilization of these tests, but the insurance company isn’t in the examination room. The highly “motivated” doctor can simply add a word or two to the patient’s symptoms to have the test approved. The EKG can be billed for chest pain even if the patient doesn’t have any. The chest X ray is indicated for a cough that the patient doesn’t have.
The doctor gets paid. The patient is fooled into thinking that he got a useful test for free. Someone else gets the bill. Costs keep skyrocketing. Any efforts by the insurers to limit payment are answered with emotional shouting about “rationing”. Rationing is when you don’t use something so someone else can have it. We’re talking about things that simply have no benefit and shouldn’t be given to anyone.
Choosing Wisely is a welcomed effort. I hope it succeeds, but I predict it will not. As long as the perverse economic incentives persist so will the useless but expensive therapies and tests. I’ve written before about how our healthcare marketplace broke and what I think will be needed to fix it. Until then, we are wise to remember that we get what we pay for. And we’re all paying for expensive and ineffective healthcare.
Doctor Panels Recommend Fewer Tests for Patients (New York Times)
Doctors seek end to 5 cancer tests, treatments (Chicago Tribune)
Doctors unveil “Choosing Wisely” campaign to cut unnecessary medical tests (CBS News)
WolframAlpha U.S. healthcare expenditures time series (click on “linear scale” by the graph to get a clear picture)