From the New York Times:
In a move likely to alter treatment standards in hospitals and doctors’ offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.
The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States. [emphasis added]
The question of unnecessary testing is one I’ve raised before, and it’s one that continues to vex me. My previous discussion, however, centered around the specific issue of tests that are deemed unnecessary by the provider but are desired by the patient. The recommendations released this week concern the opposite: tests or treatments that doctors are ordering because they erroneously think they are of benefit or for their own enrichment. (More on that last in a moment.)
Before I go further, I should stipulate that I am not an internist, and these recommendations were issued by the American Board of Internal Medicine Foundation regarding treatment of adults. Outside of the occasional “Is there a doctor in the house?” situation, I haven’t laid hands on a grown-up patient since the late 90s. Thus, my ability to pronounce of these recommendations with authority is a bit limited. I did lots and lots of internal medicine back in school, but the more time passes the mistier my recollections grow and the more outmoded what I was taught becomes. Make of that what you will.
That said, these recommendations seem perfectly reasonable to me. I was relieved to see that, with one exception to be discussed below, there was nothing that had a pediatric equivalent that I order routinely. It is high time someone started discussing the problem of over-treatment in a serious manner. I applaud the effort.
But let’s spend a little time mulling that word I bolded up there, shall we? “Profitable.” Heavens! How did that word get in there?
From the same article:
“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”
That quote makes me throw up in my mouth a little.
There is, to my mind, one reason to order a test or treatment and one reason only — it helps the patient. It may help in detecting, preventing or curing disease. I have raised the question of whether it could be considered sufficiently “helpful” to order something knowing it is “unnecessary” from a strictly medical perspective but for the purpose of creating peace of mind. (I don’t necessarily endorse that view, but think one could mount the argument.) I can think of no other defensible reason to order something than helping patients. “Because it profits the provider” is not even close.
Now, obviously we can’t wholly remove the potential for undue profit from medical decision-making. If I refer a patient to an ENT surgeon for evaluation, there’s a lot more money made if the patient goes to the OR than if the doctor looks in her ears and says “they look OK to me. Come back in six months.” There will always be some potential for unethical physicians to recommend interventions because of financial gain. It makes my lip curl to say so, but them’s the brakes. However, I have long been astounded by the obvious conflict of interest that arises when physicians are allowed to own a stake in a business that provides services they prescribe. An easy example is a radiology suite, which gives physicians the opportunity to make money from every X-ray they order. That this happens when it seems so elementarily unethical confounds the dickens out of me. Obviously I don’t have a problem with doctor’s offices owning some of their own diagnostic equipment (an EKG machine is fine, for example), but when you’re ordering EKGs for patients because it pads the bottom line then you’ve crossed a pretty blindingly bright line.
I should stop to clarify that I don’t think most doctors order these unnecessary interventions because it profits them to do so. On balance, I believe that the majority of physicians are ethical professionals who are generally intent on providing for their patients’ welfare above all. Most of these needless tests and treatments are probably ordered due to a combination of holding on to obsolete clinical practices and defensive medicine. That doesn’t make the choice to order them right, but it does save it from being contemptible.
The recommendations also include an urging to patients to question when those interventions are ordered. Any physician who is ordering these things for a good reason should be able to explain why to the patient’s satisfaction. Hell, even for interventions that aren’t on this list physicians should be explaining their reasoning to their patients anyway. But knowing that these tests and treatments are often ordered for no good reason may make those seeking care (who are, much as I dislike to think of them this way, consumers after all) more savvy about what they’re getting and less credulous when the provider’s motives are shaky.
This post is already long enough as it is, but I do also want to touch on the one intervention I do order commonly that ended up on this list.
I prescribe antibiotics for sinus infections relatively commonly. I would gladly stop, and if these recommendations actually have an impact and people stop wanting them I would be delighted. The truth is that almost all sinus infections would resolve without my doing anything at all, and I’d be inclined to let them. Why do I order antibiotics, then? Anyone want to guess?
I order them because patients demand them. And it would be great if they’d stop.
From a different but related piece in the Times:
While diagnosing bronchitis, a common respiratory infection, is often easy, treating the condition is more difficult. Medicines may calm the symptoms, but the only cure is time. Most notably, antibiotics, though commonly prescribed, are no better than a placebo for bronchitis. Yet discussing this can be a bit of a minefield for physicians, particularly when patients are used to antibiotics for such infections. So when I sat down to talk to my patient, I was surprised when she cut me off.
“If it’s O.K. with you” she said, wiping her nose with a tissue, “I’d like to avoid antibiotics, with all those side effects.”
I do have plenty of patients/parents who are perfectly content with avoiding antibiotics for infections that I am confident are viral. I am genuinely grateful for them. But I will buy you the cold beverage of your choice [note: claims must be redeemed in Las Vegas in late May] if you can find a medical provider who hasn’t tried their best to talk a patient out of a prescription for an antibiotic and failed. Then it becomes a decision about how much you’re willing to piss off your patient in order to avoid an unnecessary course of antibiotics. I would be lying if I pretended that I didn’t cave. Usually I can find something to hang my hat on when calling it a “sinus infection” instead of an uncomplicated upper respiratory infection, but the cases where I’ve genuinely suspected a bacterial source are a distressingly small proportion of total antibiotic prescriptions I’ve written for same. Feel free to shame me for my pusillanimity in the comments.
For patients to start questioning their doctors when they write out a prescription for antibiotics to treat a sinus infection would be a pretty big change from the status quo. Which isn’t to say it wouldn’t be appropriate and salubrious to do so. Just that I think it’ll take more than a set of recommendations to make it come to pass.