This mix of medical misconceptions can be harmful to your health
A mix of medical misconceptions may be hurting your pocketbook and harming your health. But there’s a ready cure at hand. Take these two evidence-based findings that challenge conventional wisdom:
When it comes to medical screenings and tests, more isn’t always better.
Early detection may not be all that helpful with some conditions and diseases, contrary to popular belief.
Think twice before you leap into more medical testing or to letting your doctor order more screenings for you. You may not want to just say no. But you need to ask this smart, important question: Why?
In this month’s issue, we talk about the why, and the why not.
Excess medical screens: big risks, big costs
We Americans spend $3 trillion a year on health care, nearly one in six dollars of our entire economy. But our system, some experts say, suffers from a “sickness” of greed and excess. According to them, we’re in the throes of an “epidemic of unnecessary care.” As health officials try to curb medical services’ soaring costs, they’re increasingly focused on an important gateway: Over-screening, over-testing, and over-diagnoses that add $200 billion in unnecessary expenses to our care, with over-treatment costing 30,000 lives a year of older (Medicare) patients alone.
Look at your own bills and see how a routine, relatively inexpensive doctor visit can blow up with added testing costs. These might include tests for cholesterol (costing as much as $1,000), Vitamin D deficiency ($50 or so), diabetes (blood sugar $20), breast (mammograms, often covered by insurance but $20 to $60), or prostate cancer (PSA test $40).
To be sure, appropriate, timely medical tests and screens can be life-changing, even life-saving. But experts—including Uncle Sam, the nonpartisan and independent Consumers Union, and more than two dozen leading groups representing an array of medical specialists—warn that American doctors and hospitals reflexively order too many tests whose potential harms outweigh their benefits.
Independent, expert advisors
You may have read about the Choosing Wisely campaign by Consumers Union, the health-focused ABIM Foundation, and the many medical groups, or the excellent recommendations of the U.S. Preventive Services Task Force (USPSTF). These and other medical science groups, made up of top independent experts, scour the best available evidence, talk with leading practitioners, and try to cut through the mumbo jumbo to help inform the public.
They’ve scrutinized whether so many of us should undergo regular thyroid screenings (no), tests for Vitamin D deficiency (no), tuberculosis (maybe), carotid artery blockages (no), blood sugar (yes), and cervical cancer (yes but depending on age). They’ve weighed in on if, except in specific conditions, we should have CT (computed tomography), CCTA (CT scans with dyes), PET (positron emission tomography) and ultra sound scans for heart and cancer check-ups. (Answer: mostly no).
You’re likely familiar with their advisories that doctors, for example, stop routine screenings for many older Americans for colon, breast, and prostate cancer. The experts’ careful explanations have attracted major attention in news stories. But the opposition may be going too far. Medical specialty groups can and do disagree with such recommendations. But some political partisans now want to pass laws to rein in the voluntary, evidence-based work of the USPSTF. That’s not smart, nor good for patients.
As Choosing Wisely and the USPSTF point out in their recommendations, it isn’t just the tests that can increase patient risks of harm, such as what can occur if a colonoscopy causes bleeding or punctures in the colon. Screenings can cause a cascade of follow-on procedures, many costly, painful, and invasive. Their “false positives” can prompt doctors to order biopsies, more tests, and exploratory surgeries. With breast and prostate tests, scans for two of the most common cancers for women and men, medical science hasn’t advanced sufficiently so tests show more than the presence of suspicious tissue or a worrisome body response (buildup of antigens in the blood, for instance). Screens can’t tell us which cancers are aggressive, potential killers that need urgent attention, and which are slow growing, might never become harmful, and might be treated with “watchful waiting.” Patients’ quality of life can be hugely affected by how their doctors look at test results and then decide their care.
Popularizing early detection
Since the 1950s, medical practice has enshrined the idea that early detection can be decisive. A recent study found a 36-fold, storm-like “surge” in medical journal studies from the 1950s to the 2010s about early detection and prevention of disease and their advantages. Has medical science fed a public misconception about the role of testing and screening in the battle to better our well-being?
Even ophthalmologists may be over-testing. Peter Provonost, a doctor, Johns Hopkins Medicine senior vice president, and director of the Armstrong Institute for Patient Safety and Quality, has written that we could save $500 million by eliminating unnecessary tests for seniors having cataract surgery. Citing a Johns Hopkins ophthalmologist’s study, he says doctors and hospitals needlessly subject these patients to extensive pre-surgical screenings as if they were undergoing a major operation. This regimen is required, even though cataract patients mostly will sit in a chair, with anesthetic eye drops and mild sedation for a procedure that affects only their eyes. Research shows complications from cataract surgery are rare, and rarer still are patients who benefit from the extensive screening. Half of the 20,000 patients who elect the procedure are forced into this big expense. Many have the surgery covered by Medicaid and Medicare, meaning we taxpayers fund this over-screening.
To hear some doctors tell it, blame for over-testing should fall on lawyers like me. GOP leaders, including Tom Price, an orthopedist and the Health and Human Services secretary, say fear of malpractice lawsuits forces too many doctors to practice defensive medicine, ordering screenings and tests, just in case, and to protect themselves. Their arguments have been refuted by independent, nonpartisan, and authoritative sources. That still may not stop them from using their unsupported ideas to strip harmed patients of their right to pursue appropriate legal redress.
But, to be fair, if we’re pointing fingers about over-screening and over-testing, maybe we all should look in the mirror and ask whether we share some blame. Why?
They’re taking what experts deem to be “low value” tests of blood, urine, and saliva for a host of conditions, including heart disease and cancer. Some companies offer elaborate, expensive high-tech imaging screens. One study, which already is showing its age, identified at least 20 vendors offering more than 125 tests for everything from non-contrast CT imaging to vitamin deficiency, heavy metal poisoning, hormonal imbalance, sexual diseases, and substance abuse.
Companies can sell screenings to patients directly without M.D. involvement, because they’re not practicing medicine. They’re racing through legal loopholes in which they must show their tests are accurate and valid but not much more. The companies involved include start-ups and big, long-established concerns.
Gene testing’s trendy
Genetic tests are a new hot frontier. The federal Food and Drug Administration raised eyebrows when it reversed itself and allowed the 23andMe company to sell straight to patients its saliva tests, which it says provides consumers both genealogic data as well as information on their genetic risk for diseases like Alzheimer’s and Parkinson’s. The FDA approval came with conditions—the company, for example, pulled back from its earlier, more extravagant claims. And it now must provide much more extensive explanations of scan results, including that its tests show disease risks and do not diagnose illness. But for now, 23andMe has a valuable lead in a growing market, and it is only adding to what experts say is its larger aim: to create a huge database of patient information. Its sources are anonymous but volunteer subjects are providing data that 23andMe can profit from by selling it to other medical services’ companies, such as those in Big Pharma.
Theranos, a scandal-ridden blood testing start-up, also sought to benefit from consumers’ eagerness for screenings. The company, a Wall Street darling once valued at more than $9 billion, claimed its proprietary approach would allow it to collect just a drop of blood from patients at pharmacies, then to run hundreds of tests at a far lower cost than any existing lab could. Journalists—notably from the Wall Street Journal—and regulators shredded the secretive company’s hype. But why did it hold such appeal? Why are companies like 23andMe flourishing, beyond the popularity of genealogy as a hobby?
What the rich do
Part of the boom in medical testing, despite its costs and risks, may rest in a troubling reality of contemporary American society: We’ve created new and extreme wealth. While many of us struggle with the costs of health insurance and medical services, some of the royally rich want their high life to extend as long as possible—including by undergoing at any cost any screen or test that might offer any health advantage. Billionaire Mark Cuban caused a social media kerfuffle by arguing that we’re on the brink of big-data and tech-driven breakthroughs in medical care, and, only by big numbers of people establishing a “baseline” of information on themselves can they reap future benefits and contribute to advances. He urged his millions of Twitter followers to undergo quarterly blood tests, then battled with health journalists and experts who questioned his ideas.
Those mobile operations, by the way, long have been under fire for providing screenings of little value. Their fees—$100 to $150— for a menu of tests may seem nominal. But look at the long lines of test subjects and do the math. The companies take in a lot of money and don’t do much for it. A healthy West Coast colleague with excess health-savings account funds ticked his doctor off by playing guinea pig. He went to a mobile site, answered questions about his health and life, got his pulse and temperature taken, blood pressure measured in his legs and arms, and a 30-second wave of his neck (carotid artery) with an ultrasound wand. Cost: $150 for 10 minutes. That was 15 years ago. He’s still on the company’s mailing list and gets re-screening invitations quarterly. Plus, he now gets junk mail for myriad medical products and services.
Caveat emptor, friend. But how about you? Are you bugging your doctors for screens you don’t need?
Skeptical patient-consumers will be key to reversing over-screening
It won’t be easy to eliminate over-screening, over-testing, over-diagnoses, and over-treatment. But patients, doctors, and hospitals are trying.
In California, hospitals are reporting progress by halting doctors’ reflexive ordering of batteries of tests that can add to the institution’s and patient’s costs, and, under existing health care reforms, can result in penalties. They’re doing so by eliminating check-boxes or buttons in electronic health records that let doctors too quickly and conveniently tick off laundry lists of screens. Some flag doctors when they try to enter into the hospitals’ computer systems any treatment plans that contravene recommendations in Choosing Wisely or by USPSTF and other evidence-based standards of care. Many hospitals meet regularly with medical staff members to show them detailed records of how they care for their patients, what it costs, and how it compares with national standards and their peers internally and across the country.
These measures can be beneficial not only in curbing over-screening and over-testing but also in bettering care—some research shows that treatment outcomes improve when doctors reduce testing and follow hospital standards. These measures also can play crucial roles in getting doctors and patients engaged in the tough and too-often-skipped conversation about the overall and soaring costs of medical services.
One of your fundamental and most important rights in medicine concerns your informed consent for any medical procedure. Informed consent expresses a concept at the core of any free society: Each person has a right to decide what to do with his or her own body, as long as he or she doesn’t hurt someone else. Your doctor, knowledgeable in her field, must provide you with full information so you can make sound decisions about your care. You may find, as research has shown, that once screens and tests are explained, you may skip them.
You and your loved ones should feel free to ask your doctor about medical tests or screens: Are they diagnostic or opportunistic? Do you already have symptoms or display evidence of a possible disease or condition that your doctor wants to diagnose and confirm to set a course of treatment? Or, as long as you’re in the office or hospital, is your doctor measuring or checking you or the way your body is functioning? You should ask your doctor how she’s accounting for your age, gender, overall health, and family history when ordering tests or screens. What are your risk factors for specific diseases or disorders, and what are your preferences about your care? The World Health Organization says that, when it comes to screenings and tests, they should be done only: for diseases with serious consequences; if they have potentially clear health benefits; and if they are reliable and not harmful in themselves. WHO cautions that, with testing, there must be an effective treatment for a disease when detected at an early stage–and scientific proof that treatment is more effective when started before symptoms arise.
You need, of course, to get your doctor to discuss with you the cost, value, and outcomes of screens or tests. The priciest screen isn’t always best for you, meaning it might not reveal much, might not be needed, or might come with risks that outweigh its benefits. If you tweak your back, you may not need imaging tests with their radiation exposure risks and costs of up to $6,000, when rest and a few days of discomfort will deal with your issue. A top specialist beat a friend of mine to the punch, telling him he was ordering a $150 exam rather than a recommended $7,000 test. He said the costly screen informed him less—and he had demonstrated with a volume of patients, treated successfully, the value of the cheaper test. It isn’t easy for patients to determine such issues. No one expects you to read a pile of medical journals. But your doctor can help you, for example, by sharing the easy-to-understand Number Needed to Treat (NNT) of a screen, drug, or procedure. (See sidebar)
When all’s said and done, what did a given screen or test show? Your doctor should spend appropriate time with you to discuss results and next steps. Understanding and interpreting tests isn’t always easy and clear. Medicine can be subjective, as much healing art as science. Your results may be skewed: Did you take that cholesterol test after returning from a learn-to-cook vacation in Paris? Did you slip up and eat jelly doughnuts before having a fasting blood sugar test? Doctors are finding great value in screening selectpatients for the BRCA gene, an indicator of increased cancer risks. But what happens if it is found is complex and can be a freighted matter requiring careful explanation and consideration before deciding next steps. Frankly, my involvement in a BRCA testing-and-misdiagnosis lawsuit leaves me scratching my head about do-it-yourselfers eager and quick to undergo genetic tests and other medical screens. Most of us grow out of playing doctor early on, right?
But my best wish to all is that we just stay so healthy that we can avoid needing any tests, screens, or other medical services at all!
IN THIS ISSUE
Excess medical screens: Big risks, big costs
Will ‘DTC’ tests really make us healthier?
Skeptical patient-consumers will be key to reversing over-screening
An annual exam? Maybe not.
A helpful number to assess medical tests & treatments
There are worthwhile preventive measures that can be part of a periodic visit with your doctor. You’ll find that many of these, as well as your caregiver’s time, may be covered by existing health insurance plans, making them affordable, too.
If you’re a superstar at work, maybe a CEO or other C-suite executive, your company may offer you a popular perk—the executive health screen or comprehensive physical. These often are performed at big-name medical centers (Johns Hopkins, the Mayo or Cleveland Clinics, etc.) and cost corporations from $2,500 to $10,000. You’ll undergo a broad range of screens and tests, potentially including some with higher risks (full body imaging scans). You’ll spend quality time talking with medical specialists, and you’ll stay in luxe quarters. It may feel like you’re visiting a spa.
Just so you and your company know, the value and effectiveness of these executive health programs hasn’t been shown.
A helpful number to assess medical tests & treatments
Evaluating drugs and medical therapies can be confusing for lay people. The Number Needed to Treat (NNT) offers a quick, single figure that can be helpful.
The NNT gives a short-hand summary of how many people would need to be treated (with a drug or therapy or screening test) so that one individual benefits. The number comes from scrutiny of the best available medical-scientific evidence,
Smaller NNT numbers are generally better. Look at some NNT’s for:
high-risk smokers and CT scans—the number needed to treat to prevent one death—is 271. But 1 in 4 patients also is harmed by a false positive, while 1 in 30 is harmed by related, unnecessary surgery, and 1 in 161 patients is harmed by related surgical complications.
You can check out many more NNT numbers at this website sponsored by a group of doctors who are expert in number-crunching.
HERE’S TO A HEALTHY 2017!
Patrick Malone Patrick Malone & Associates
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