Will Doctors Stop Ordering Too Many Tests?

By Jane Farrell

Ask enough people and most will say that their physician has a fairly decent reason for ordering tests and prescribing treatments. Recent studies show that their doctor may be among the growing number of physicians who disagree.

In a survey of 600 physicians conducted by the American Board of Internal Medicine Foundation, almost 3 out of 4 admit the frequency of unnecessary tests and procedures is an unnecessary burden on the US Healthcare System and creates a problem for Americans consumers. The same percentage, about 75 percent, admit that the average physician orders unnecessary procedures and tests at least once a week.

Other pertinent finds in the survey:

66 percent feel an enormous responsibility to help their patients avoid unnecessary tests

53 percent say that even if they know a test is unnecessary, they will order it anyway if the patient insists

58 percent feel they are the best to address the problem of excessive testing. Only 15 percent felt the government was best

70 percent say that after they talk with a patient about bypassing an unnecessary test, the patient agrees

The survey came twenty-four months after the ABIM’s introduction of its program, Choosing Wisely, that encourages doctors to think about whether certain tests are necessary for the patients’ condition.

The British Medical Journal sponsored conference, “Preventing Overdiagnosis” was co-sponsored by Consumer Reports and Dartmouth University. The 2013 conference listed its goal as identifying  the excess in medical care and finding ways to fix the issue.

The general consensus of physicians attending the conference was that developed countries — especially the U.S. — were over-testing for disease, over-diagnosing and overtreating. Termed “wasteful medical care,” the habit does more harm than good to the patient, the conference found. It also diverted scarce medical resources from people who need care and treatment.

Several discussion panels looked at the problem of over testing and over diagnosis and found:

Routine PSA screening for prostate cancer was the clearest example of excessive testing. The committee said that PSA testing routinely done on men over a certain age was oversold, dangerous and an expensive flop.

Lowering the threshold of disease definitions has led to identifying conditions that just aren’t there. The idea of early diagnosis of diseases such as heart disease, hypertension, diabetes and more has misidentified too many people who really are not at risk.

Medical technology has become a runaway problem. Physicians are finding that if enough CT scans are done, structural abnormalities can be found in just about anyone. Most results are incidental and don’t have any clinical meaning and often otherwise healthy people get hazardous cancers from the CT radiation that served no purpose to begin with.

Physicians habitually order huge batteries of laboratory tests and treating the results of those tests instead of doing what is best for a particular patient. The conference called for the retraining of physicians already in practice and a change in medical teaching for new doctors.

Big Pharma needs taming and shaming. The direct to consumer advertising that is prevalent in America serves to push individuals to demand unnecessary testing by their physicians.

Employers and government payors need to be smarter consumers of healthcare services and stop reimbursing for tests and treatments that do more damage than good.

Consumers need to be educated and not buy into the idea that more is necessarily better.

Since the conference, fifty medical professional associations in America have cut back on inappropriate testing and treatment. The British Medical Journal and Consumer Reports are playing a leading role in the change and have become platforms for spreading the word.

Included in the Preventing Overdiagnosis conference were 330 policy makers, researchers, consumers and clinicians and came from 28 countries. The struggle is far from over. The entities that benefit from massive over-diagnosis command billions of dollars a year to encourage and promote the idea of excessive testing. The forces that support the concept of rational decision-making only access a few million dollars a year.

So smart money is betting on the maintenance of the status quo and the continuation of the program as prescribed by the big bucks.

In Seeking Sickness: Medical Screening and the Misguided Hunt for Disease, Alan Cassels a researcher at the University of Victoria in British Columbia, says a long-term passion has been to prevent disease rather than to treat it because it is easier to follow a preventive strategy.

“There is an enormous amount of effort and research invested by the traditional community into medical screening procedures,” says Cassels.

Cassels isn’t alone in his thinking.  Dr. Marina Gafanovich, a well-respected New York physician and founder of Physical Exam NYC, says, “The trouble is conventional medicine views medical tests as ‘prevention,’ when in reality there is nothing preventive about them. They’re diagnostic tools and some aren’t even all that accurate at diagnosis.”

A study by the Cochrane Library found that general health checks failed to reduce morbidity or mortality although the number of new diagnoses increase. The study indicated that important harmful outcomes such as the number of worthless, follow-up procedures were not considered or reported.

Since regular health checks are usually considered to be a part of disease prevention, the Cochrane Library’s study may be surprising. After reviewing the clinical outcomes of almost 180,000 people, the researchers found out that regular health check-ups didn’t make a difference in terms of living long. They did find that regular screening led to increased drug use.

Researcher Lasse Krogsboll of the Nordic Cochrane Centre in Denmark said, “”What we’re not saying is that doctors should stop carrying out tests or offering treatment when they suspect there may be a problem. But we do think that public healthcare initiatives that are systematically providing general health checks should be resisted.”

Of the thousands of treatments evaluated, only one stood out as a having a clear benefit of treatment. A respiratory intervention in newborns consistently showed a reliable, very significant drop in death rates.

“I guess the summary statement would be to go into medical screening with your eyes open,”  Gafanovich said.