Some medical care may not help. Alternatives may not either.

‘Why Doctors Still Offer Treatments That May Not Help’, by Austin Frakt in the New York Times, August 27, 2019, is a well-done article that, despite its title, is fairly optimistic. He reports that while about 50% of current medical treatments no not have good evidence supporting them, only 3% have evidence showing them to be harmful, and another 6% unlikely to be helpful. This means about 41% (or only 41%, if you prefer) have good evidence that they are helpful.

Frakt cites some of the research on health interventions that do not work, or may even harm, quoting leading researchers Vinay Prasad and Adam Cifu (although he does not mention John Ionannidis, arguably the father of the field). He discusses the important “Choosing Wisely” campaign, initiated by the American Board of Internal Medicine Foundation, that asks each medical specialty society to identify at least 5 things often done in their specialty which usually should not be done. There is not, however, always consensus. For example, among its 20 recommendations (a high number that continues to grow, perhaps because of its discipline’s broad scope), the American Academy of Family Physicians (AAFP) recommends against imaging (including MRI and CT) for uncomplicated back pain, as does the American College of Physicians (Internal Medicine) (see ‘Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some, August 19, 2018).  Yet, neither the American Academy of Orthopaedic Surgeons, or the various groups of radiologists who perform these procedures, make this recommendation. Of course, both stand to benefit financially from doing these procedures.

It is concerning to think that, at least in some cases, financial benefit may influence the selection of some medical societies’ “Choosing Wisely” recommendations. Sadly, it is not a surprise, and financial benefit is, I believe, the reason for the use of many unproven treatments. Another important reason is an understandable reluctance for providers to abandon therapies that they have used for many years and believe to be successful. After all, if 50% of treatments do not have good evidence that they help or harm, many probably often do help, even if most of the evidence is anecdotal. Much more malicious, however, is the intensive marketing of new drugs and therapies to physicians by drug and device makers with a strong financial profit motive.

Frakt provides a litany of therapies-since-found-not-to-work-or-even-do-harm, including hormone replacement for post-menopausal women. The only drug he specifically names is Vioxx®, the “miracle” anti-inflammatory pulled from the market when it was found to cause heart disease (at least publicly found; the manufacturer actually knew it before it was released!). He also mentions “tight blood sugar control in critically ill patients” (and actually, probably most patients). This certainly relates to drug. The plethora of new, expensive, and marginally advantageous diabetes drugs is a testimony to their profitability. Ironically, it is often the same physicians who are unwilling to give up on treatments that are unproven or even proven to be of no benefit or of harm who are the first to begin using new (and, redundantly) more expensive drugs heavily promoted by the manufacturers.

Of course, it is not just diabetes drugs that are expensive. Compared to some of the newer drugs for rare diseases they seem like a bargain. In “The $6 million drug claim”, Times writers Katie Thomas and Reed Abelson discuss a woman who has $1 million in drugs to treat her condition in her refrigerator! While in her case they were paid for by her husband’s union, the cost can still be backbreaking: “At one point in 2018, for every hour that one of the union’s 16,000 members worked, 35 cents of his or her pay went to Alexion to cover the Pattersons’ prescriptions.” And what about those who have poor insurance, or no insurance? Or a union that goes bankrupt paying for them? Alexion, of course, does well, though.

A new law allows “gravely ill” patients the “right to try” drugs that the FDA has not approved. It sounds good; as a friend told me “I figure if I’m going out and they want to try something that might kill me I haven’t got much to lose. At best I’m cured. At worse, I go out but knowledge is gained.” Except for maybe dying sooner or more painfully, or possibly going bankrupt. It is not uncommon for doctors to suggest something new, unproven, or even a treatment that has already failed, one more time. Not everyone in this country has good insurance, and if your insurance company appropriately refuses to pay because there is no evidence of efficacy (yes, they are sometimes right!), you are on the hook for the bill. You may be dying, but your family may need the money you were saving for retirement. Thus, there may be a great deal to lose.

A certain percentage of people will take all this to mean that mainstream medicine is not to be trusted. This is definitely an overreaction, although a healthy skepticism is warranted, especially when the treatment is incredibly expensive and it is obvious that somebody (or some corporation) is making a killing on it. Some people will decide to pursue only what used to be called “alternative” medicine. These practices, often with hundreds or thousands of years of experience, are often called “complementary” and are now frequently offered along with mainstream medical therapies in “integrative” practices. But the same cautions must apply; because something is different, or traditional, does not make it necessarily either effective or safe.

For example, while people sometimes believe it is safer to choose only “natural” medicine, because a therapy grows in nature does not mean it is necessarily safe. Earlier in my career, medicine virtually abandoned the use of digitalis, made from the natural plant foxglove, to treat heart disease, after it had been used for decades. The key point is that if a substance works biologically and has “good” (i.e., desired) effects it can also have “bad” (i.e., undesired, or “side”, effects). This is true if it is straight from the plant, modified and standardized, or completely created in the laboratory.

Another real danger is what Frakt calls “wishful thinking”. Being optimistic and hoping that things will turn out well is good, and often useful when confronting serious illness. But when this transitions into the realm of “magical thinking”, being convinced that something good will happen to you because you want it to (or vice versa, that something bad will not happen because you don’t want it to), or believing a treatment will work because it is “natural”, or because your doctor recommended it in the absence of evidence, it is a real risk. “Magical thinking” is normal in three year olds, but dangerous in adults.

So what to do? Be open to new treatments, but do not reject the old, whether “traditional” or medical. Ask for evidence for treatment, such as when just changing a drug from an inexpensive standard (say, metformin for diabetes) to a new, costly one. Learn to understand probability, and ask for numbers. Do not reject anything out of hand, but do not believe that something will work just because you want it to.

Stay skeptical but not intransigent. Look for the evidence. And look also, when something is expensive, for the profit motive. Cui bono? It may not always be you.

Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some

The American Academy of Family Physicians (AAFP) has added five new recommendations to its Choosing Wisely campaign. I have discussed “Choosing Wisely” before (‘“Eggs Benedict” and “Choosing Wisely”: Often the best thing to do is nothing’, April 14, 2012), but will briefly review it. First introduced by the American Board of Internal Medicine Foundation (ABIM-F), the program calls for each specialty society to list at least five things that are done by members of that specialty but either should not be done at all or should only be done in far more restricted circumstances that they currently are.

The five new recommendations by the AAFP bring their total to 20; this is good, because many other specialty societies have never expanded upon their original five. And for some of those groups, even those original five were kind of tentative, almost like “well, this test or procedure is not good, so you probably shouldn’t use it too much”.  One reason Family Medicine has more is because the field is so broad and its practitioners care for problems in all areas, but I fear that another reason is the reticence of some specialty societies to make negative recommendations about things that their members make a lot of money from doing, even if they are not medically indicated. As I noted in ‘Medical interventions we shouldn’t be getting: issues of cost, health, and equity’ (December 12, 2015) regarding imaging for uncomplicated back pain:

…some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the American Academy of Orthopaedic Surgeons in their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients.

The radiologists, who perform the MRIs and CTs, also did not recommend against this procedure.

The radiologist societies also recommend screening for lung cancer with low-dose CT scans in smokers and former smokers, and in fact, to date, none of the specialty societies are recommending against it. There is some evidence that this (not inexpensive) test may be able to detect lung cancer early in many people, sometimes while it still can be effectively treated, but even this is not certain. Rita L. Redberg, MD, in an editorial in JAMA Network “Failing Grade for Shared Decision Making for Lung Cancer Screening”, notes that while (payment by Medicare for) the test was approved on the basis of one positive study, three subsequent studies have not shown the benefit. In addition, it is not without risk of harm. The harms come not only from radiation exposure, but from complications of the biopsies needed to follow up on positive tests. And, also noted by Redberg, 98% of positive tests are “false positives”, where the patient does not have cancer. Some of this high percentage of false positives comes from testing the wrong people (“screening creep”, where a test that has been shown to be of benefit in a limited population is incorrectly assumed to also be of benefit to a wider group). the US Preventive Services Task Force (USPSTF) recommends that the screening only be done on the patients for whom it is indicated (!!), and only after the doctors engage in “shared decision making” (SDM) with their patients by helping them understand both the potential risks as well as benefits to the test, and what their individual probability of each is.

Apparently, doctors do not do this, as demonstrated by the research article that Redberg’s editorial accompanies, “Evaluating Shared Decision Making for Lung Cancer Screening” by Brenner, Malo, Margolis, et al. Taping and analyzing recordings of doctors recommending this test to their patients, they found no evidence of the physicians presenting the important information and engaging in SDM. It was a small sample (this is difficult and time-consuming work), but as Redberg points out there is no reason to imagine that overall practice is significantly different. While this study specifically looks at low-dose CT screening for lung cancer, and finds that SDM doesn’t happen often, this is a concern for many other tests and interventions that are often done when they are not indicated, and rarely have the risk/benefit presented to people so that they can participate in SDM.

One example of such a test is the use of screening pelvic examinations (the part where the provider puts her hands in and feels around, not the Pap smear part) in non-pregnant women. One of the AAFP’s new “Choosing Wisely” recommendations (#16) appropriately comes out against it: “Don’t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer”.  This is because the most basic characteristic of a screening test (essentially, any test – whether a physical exam or lab or x-ray – done in asymptomatic people) is that there has to be a disease that the test can, with some reasonable rate of accuracy, screen for. There is no condition that can be screened for by a pelvic examination (including ovarian cancer, which has been cited, and is always too advanced to successfully treat by the time it can be felt). I have been teaching students and residents to not do “screening” pelvic examinations in asymptomatic non-pregnant women for decades.

For similar reasons, previous AAFP “Choosing Wisely” recommendations, had already recommended (#5) against doing Pap smears in women in whom it is not indicated (those who are under 21 or have had removal of their cervix for non-cancer disease), and in women over 65 who have had negative prior Paps and are not at high risk for cervical cancer (#9), and not requiring either Paps or pelvic exams for prescribing oral contraception (#15). In addition to not doing a screening test when there is no disease to screen for (pelvic exams), they should also not be done when the risk is very low and lead to excessive false positive tests. This seems like a lot of “don’t dos” in the same general area of women’s screening, but it is warranted not only because family physicians do a lot of such screening, but, more embarrassingly, because many OB/Gyn specialists both continue to do them and to teach students and residents to do so. Indeed, not doing screening pelvic examinations is distinctly not one of the 10 “Choosing Wisely” recommendations by the American College of Obstetricians and Gynecologists (ACOG).

Yes, OB/Gyns do make some of their living doing such procedures (as do family doctors), but frankly it is a small percent compared to doing surgical procedures. Sometimes tests and procedures continue to be done even when they are not indicated (or potentially harmful) because of tradition. Or because of publicity campaigns run by disease-specific advocacy groups, especially for various types of cancer, that sow fear rather than truth.

But when such tests and procedures continue to be done, even in part, because those who perform them, the doctors and hospitals and laboratories and device makers, make money doing them rather than for medical benefit, it is reprehensible. And, even more, it saps funds from other important health-related care, particularly for those people who have the least money and are least likely to be insured. We do not have a unitary national health system in which money not needed in one area can be easily transferred to spending on necessary care for other people or conditions, but we need to get there.

It is unacceptable for people to get tests and procedures that are dangerous and of no benefit regardless of funding. It is similarly wrong for even relatively benign tests and procedures that are not medically indicated to be done because those performing them make money. But it is worst that many people do not get even basic, indicated, beneficial care while money is being wasted, or worse, on these other procedures.

The terribly flawed attitude of treating healthcare as a business was illustrated by a comment from Charles Bouchard, senior director of theology and ethics at The Catholic Health Association, in a NY Times article that found fewer than 3% (all in Washington State, which legally requires it) of Catholic hospital websites “contained an easily found list of services not offered for religious reasons.” He said '“I think that any business is not going to lead off with what they don’t do. They are always going to talk about what they do do. And that goes for contractors and car salesmen. They are not going to start off by saying, ‘We don’t sell this model,’ or ‘We don’t do this kind of work.’”

That’s the problem. Selling things people do not need to them if they have money (and not offering things there is no profit in so doing) is a common way to run a business. It is no way to run healthcare.

Medical interventions we shouldn't be getting: issues of cost, health, and equity

Many of us are concerned about the cost of medical care, particularly in the US. We are also concerned about the care that we, ourselves or our families and friends receive. We want the diagnostic tests and treatments we get to be likely to benefit us and to not cause us harm. Or, if there is chance that we may be harmed, that the probability and degree of benefit exceeds the probability and degree of harm. Sometimes there can be a tension here: we want to spend less on health care globally (and certainly less on the portion that just goes into the pockets of big corporations, like pharmaceutical companies and device manufacturer, insurers and huge health provider networks), but don’t want to scrimp on things that may benefit us. Especially when we are well-insured and not paying for it directly out of our pocket.

Fortunately, there are many times when these two different interests come together, when tests or treatments that are costly are also of no benefit to us, and may cause us harm. The problem is that sometimes our doctors recommend them to us anyway, or, frankly, we ask for them (because we’ve read about it on the Internet or seen an ad on TV or because a doctor recommended it for our Cousin Shirley who had the same thing, or at least something that sounded a little the same). How can we, as patients, know when our doctors are recommending a test or treatment that is not indicated for us, will not benefit us, may even cause us harm? How do we know when we are appropriately advocating for ourselves as opposed to asking for something inappropriate? It is not easy, but we can try.

One answer is NOT to reject all medical recommendations for diagnosis or treatment, to assume that something “natural” is always right. Medicine can do a lot; it can treat a lot of illnesses that can cause you to suffer or die prematurely. There are many tests that are proven useful or valuable for making diagnoses. Another is to not reject things simply because they cost money (difficult when you don’t have much and they cost a lot), but also not to ask to have them because you have money (or insurance). To a great extent it is asking your doctor questions, asking about the degree of benefit, hoping that they are up to date, trying to question what the likely benefit is from another test or treatment, especially if costly. It also, sadly, means understanding if the doctor themselves, or a company they work for, stands to make profit on the test or treatment, since this creates a conflict of interest (but certainly does not mean that it always or usually isn’t appropriate).

There is an entire medical literature on medical overuse, and your doctor should be familiar with it, or at least the most egregious overuses that are in her/his field. A recent article in JAMA Internal Medicine , “Update on Medical Practices That Should Be Questioned in 2015”, by Morgan et al., reviews some of these.[1] The authors reviewed the literature on articles published in 2014, and came up with 104 that at least one of the 3 thought was very important, and 33 that all agreed were very important. The article reports on the “Top 10”, because this is a nice, round number and because it seems to be a manageable number of things for doctors to remember. Just these 10 represent a lot of excess tests and excess expense.

I will summarize some of these 10 (the ones I feel are most relevant; you can find them all in the article), both to remind doctors and other health care providers who might not have seen it, and because other readers may have had these tests recommended. Before doing so, it is important to review the difference between a screening test, done on the general population (or a subset of it) who don’t have any symptoms, and a diagnostic test, which may be the same test done on someone with symptoms related to what that test tests for. Frequently a test is useful for diagnosis for someone with symptoms but in someone without may not only be of little use, but find “false positives” that end up leading to more testing with more cost and greater risk.

• There Is No Benefit to Screening for Asymptomatic Carotid Stenosis.  None, for screening. Ultrasound or other tests may be of value for people with TIAs or other symptoms.
• Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. Again, none, for screening. You can’t screen for ovarian cancer. I have been trying to convince my residents of this for years, despite their being often taught otherwise by OB-Gyns. This is the part where the provider puts his/her hands inside. It is NOT the same as a Pap smear, which is recommended for screening.
• Head Computed Tomography Is Often Ordered but Is Rarely Helpful. Often finds clinically insignificant abnormalities. Also, often repeated with no added benefit. (“A retrospective cohort analysis reviewed 130 patients admitted for any cause at least 7 times during a 1-year period to a tertiary care center. Patients received a mean of almost 7 CT scans, including 3 head CT scans. More than one-third (36%) of head CT scans were ordered to evaluate for altered mental status. Only 4% (7/127) of head CTs had clinically significant findings that resulted in a change in management.”)
• Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms.  Study is from S. Korea, where they screen for it.
• There Is No Benefit to Paracetamol (Acetaminophen) for Acute Low Back Pain. “The median times to recovery were 17 days in both of the paracetamol groups and 16 days in the placebo group.” This does not mean we should be using opioids, though. In fact, when we give opioids for good reasons, like postoperative pain…
• Postoperative Opioid Use Continues Past the Postoperative Period.

Some overuse comes because practices once felt to be appropriate, but now shown not to be, are being taught to trainees, who either don’t know or are loathe to disagree with their instructors. Some comes, consciously or not, from the potential for providers to make money. Another recent JAMA Internal Medicine[2] study looked at family medicine and internal medicine residents who saw “secret shoppers”, standardized patients who were requesting inappropriate imaging. About 25% of the time the tests were ordered, which could be seen as either bad or good (75% of the time they weren’t). The study also showed no difference between those residents who got significant feedback and those who didn’t, and similar (and generally good) techniques of communicating to the patients why these were not indicated. An interesting wrinkle is that some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the  American Academy of Orthopaedic Surgeons in their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients. (By the way, among the recommendations of the AAFP is not doing screening pelvic examinations!)

What is the social justice issue here? After all, tests and treatments that are not indicated should not be done on anyone, regardless of financial or insurance status, racial or ethnic characteristics. Indeed, one could argue that those with more money or better insurance would be the most likely recipients of extra tests. But poorer, or less well-insured, people often don’t get the tests and treatments that they actually need (which has often been discussed in this blog; see for example Dead Man Walking: People still die from lack of health insurance, November 17, 2013), while tests and treatments are overused for others. This creates the (accurate) perception of a two-class health care system, and the (sometimes, perhaps, less accurate) perception that the disadvantaged are, in addition to not getting care they need, are not getting discretionary care that benefits the wealthy. Also, the more money spent globally on unnecessary medical care, the less available for necessary non-medical initiatives (housing, food, education) that would actually create better health.

A single payer system would not in itself achieve this goal, but it would create far more equity in the allocation of healthcare dollars, and at least eliminate the profit motive that might impact the recommendations of some providers and healthcare institutions.

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[1] Morgan DJ, Dhruva SS, Wright SM, Korenstein D, Update on Medical Practices That Should Be Questioned in 2015, JAMA Intern Med. 2015 Dec 1;175(12):1960-4. doi: 10.1001/jamainternmed.2015.5614.

[2] Fenton JJ, Kravitz RL, Jerant A, et al., Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial, JAMA Intern Med. Published online December 07, 2015. doi:10.1001/jamainternmed.2015.6840

Medical testing: is it about quality?

In her New York Times “Well” blog of April 13, 2015, physician Abigail Zuger comments upon “Quantifying Tests, Instead of Good Care”. She discusses a variety of factors that lead to physicians ordering more and more tests. In part, this is the simply the result of the advance of technology and thus the profusion of tests that can be done --  laboratory tests, imaging (like x-rays and their ever more complex cousins), and even parts of the physical examination (“Yes, little blood pressure cuff over there in the corner, that means you”) --  which sometimes can be seen as meaning they should be done. Other factors are about money. The tests cost money, a negative for patients and insurers, but they make money for the laboratories and imaging facilities and the hospitals which often own them, and frequently employ the physicians doing the ordering. Dr. Zuger notes that “Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.”

Another impetus is our desire – patients and physicians alike – to find out what is wrong when there is something wrong. Or, when there is nothing really wrong, to perhaps prevent later disease by finding something hidden lurking inside. There are all these tests we can get! The patient may have had many of them before, ordered by another provider, or know people who have had them. They hope that something will give them an answer. The doctor may feel that there may be an answer out there that s/he might miss if a test is not ordered, or if s/he is a primary care physician that a specialist might order these tests so maybe we should do it first; after all, it sometimes seems as if one thing specialists do when we refer patients to them is order a bunch of tests that we could have. Or, and this is a big focus of Dr. Zuger, that their “quality ratings” may suffer if s/he doesn’t order these tests.

Quality ratings are measures of things that doctors should do (or, sometimes but more rarely, should not do) for patients with certain conditions or complaints; increasingly, insurers, employers, and third-party groups are assessing the quality of care that a physician delivers in this way. Are these recommendations not based on evidence? In many cases, they are. For prevention, the US Preventive Services Task Force assesses the degree to which tests may be indicated or not for different people, often based upon their age and sex. It gives them ratings: ‘A’ is strongly recommended based on good evidence, ‘B’ means there is some, but weaker, evidence to support doing it, ’C’ means there is conflicting evidence and patient preference should be taken into account, ‘D’ means not recommended (might even be harmful), and ‘I’ means insufficient evidence to assess. A smart phone app, ePSS, can be downloaded by anyone; put in age and sex and it tells you which preventive tests are recommended.

Of course, not all doctors do all the recommended screening tests, and frequently they do tests that are not recommended (e.g., PSA to screen for prostate cancer) or more frequently than recommended (Pap smears to screen for cervical cancer), or in people for whom the test is not recommended (mammograms in younger women). When it comes to diagnostic testing rather than screening, looking for the cause of something when the patient is actually ill, there is even less consensus, and often a prevailing attitude of “more (testing) is better”. One effort to combat this is the Choosing Wisely campaign begun by the American Board of Internal Medicine Foundation. This campaign asked specialty societies to identify 5 or more commonly-done tests or interventions in their specialty that should not be done. However, the same recommendations are not always endorsed by every relevant organization. For example, the American Academy of Family Physicians recommends “Don’t do imaging for low back pain within the first six weeks, unless red flags are present.” Great, but neither the American College of Radiology nor the American Academy of Orthopaedic Surgeons, arguably the groups that could make money from this, has such a recommendation.

And then there is the risk. Some of the tests receiving USPSTF ‘D’ recommendations are more than not helpful; they can lead to harm, and this is even more true of the many potential tests that can be done looking for disease. Discussing the work of a collaboration at the Dartmouth Medical School that looks at the utility of tests, Dr. Zuger notes that such iconic treatments as controlling blood pressure can lead to bad outcomes in many older people where the benefits (avoiding stroke and other complications) begin to be outweighed by the risks:  “One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, with death rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster. Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds.”

This is just the tip of the iceberg. Tests cost money, and often show results that lead to more tests, and then maybe to procedures (biopsies, for example) that maybe show abnormalities that lead to bigger interventions. And, sometimes these interventions are life-saving, but not always. Or maybe, even, not often.  And they do often have side effects, some of which are not insignificant. The person in whom a series of tests identifies cancer and is then treated and then survives is almost always grateful for the testing and the treatment, although in many cases they would have survived just the same with no treatment, and without the costs both in dollars and in side effects. The classic example is prostate cancer, where the evidence of any treatment making a difference in survival is weak at best; it is either a devastating disease from which one dies, painfully, or more commonly a benign condition that one dies with but not from but which treatment seems to have little influence on. Except for the cost, and the non-trivial side effects of impotence, incontinence, and the effects of radiation on the rectum.

Increasingly, data is showing that much breast cancer is similar. As discussed in my December 2012 blog post “More on mammography: just because you don't like the results doesn't make research junk science”, a large study by Bleyer and Welch showed that, with new and more sensitive mammographic screening, many more women are being diagnosed with early-stage breast cancer. However, despite treatment, we are not seeing anything like that reduction in late-stage breast cancer, which means most of those early stage cancers would not have progressed at all. And yet every woman diagnosed and treated sees herself as a survivor who has been cured, even in those cases where progression would not have occurred. In his wonderful recent New Yorker article “Overkill” (May 11, 2015), Atul Gawande notes that we treat all “cancer” as if it were rabbits in a pen who have to be chased down before they escape, when in fact many cancers are “birds” that have flown away and are gone before we can do anything and many others are “turtles” who are not going anywhere whatever we do.

The goal of medical care is now to achieve the “Triple Aim” of high quality, patient satisfaction, and lower cost. As with many things that come in threes, it is not that hard to achieve two but very challenging to achieve all three. Patients satisfaction is important, but not at any cost. Cost control is good, but not if it seriously limits quality. One place to start, then, is with quality, and specifically not doing what is useless or even harmful as assertively as we do what is likely to be of value.

And, of course, to make sure that it is the disease or risk of disease that determines what tests are done, not people’s insurance or socioeconomic status, ethnicity, gender or personality.

"Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing

Years ago (OK, decades ago), when Woody Allen was a standup comic, he did a short, famous bit called “Eggs Benedict”. The narrator (let’s say “Woody”) is having pain in the chestal area (a great formulation which has long been popular in my house). He is pretty sure it is heartburn, but is worried and doesn’t want to pay the $25 to see a doctor (I told you it was a long time ago). Luckily his friend, Eggs Benedict, is having the same kind of pain. He figures if he can get Eggs to go to the doctor, he can find out what it is and save money. It works, and Eggs finds out it is heartburn. Two days later, he discovers Eggs is dead. He immediately checks into the hospital, has all kinds of tests, and discovered he has – heartburn. The bill is $110 (it was a really long time ago!) He goes to see Eggs’ mother and asks if his friend suffered much. “No,” she says, “the car hit him and that was it!”

I was thinking about this story when I was asked to call into a local radio talk show to comment on “Choosing Wisely”, an initiative of the American Board of Internal Medicine (ABIM), which calls on medical specialty societies to list 5 tests or treatments frequently performed in their specialty that they recommend not be done, or not be done on most patients. In the recently released report, 9 medical specialty societies are represented, for a total of 45 recommendations, which can be found here. The 5 for my own specialty, Family Medicine, listed by the American Academy of Family Physicians’ (AAFP), were:

1.  Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

2. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

3.  Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

4.  Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

Each is backed by the evidence, and is accompanied by a summary of the reasons. For example, for #2: “Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 % of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.” Big money for a treatment that doesn’t work, and can cause bad side effects (allergies to the antibiotics and increased resistance of bacteria to antibiotics, for two).

The talk radio hosts had questions, especially about treatment of cancer. One of the American Society of Clinical Oncologists’ (ASCO) recommendations is “Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.”  That seems like a no-brainer to me, but they wanted to know “What if a patient wants treatment for cancer anyway?” I said I thought it was the responsibility of the doctor to point out that the treatment would not help, and would not only cost money but would have a lot of toxic side effects; I said that I thought most people, if they knew they were going to die from their cancer and the treatment would not help, would not wish to spend their last days and weeks nauseated, losing their hair, and being unable to interact comfortably with their loved ones.

The radio hosts also said “We are always told patients should be self-advocates. What if advocating for ourselves we say we want antibiotics for our sinusitis?” I said that self-advocacy was really important, because no one but the patient and their family could really identify what their health goals were. But this was different from deciding what treatment you wanted; going to the doctor is not going to the grocery store with your shopping list that may include both healthful and bad-for-you foods. It is critical that you identify where you want to go and work with the doctor, or other provider, to come up with a plan that is mostly likely to get you there safely and effectively.

Coincidentally, the same week I facilitated the discussion about futile treatment at the end of life for a group of third-year medical students in their medical ethics course. They had just received a lecture from a distinguished medical oncologist, who presented the four core principles of medical ethics: Autonomy, Beneficence (do good), Non-maleficence (do no harm), and Justice. They also read several articles documenting cases in which end of life decision-making did not go smoothly or well, and the article “How Doctors Die” by Ken Murray, that I have previously discussed (How people die, and how should we?, April 7, 2012). One of the cases involved a patient with terminal cancer who had already failed treatment, and for whom further treatment would be futile (although not without adverse effects). He had agreed to hospice, and to comfort care, until a relative (a physician!) came to town and demanded additional treatment for him, and convinced him to as well.

The medical students, who had  all been through clinical experiences and most of whom had been part of teams that confronted dealing effectively with dying patients, were in agreement with the physician in the article, and with each other, that the treatment was futile and would be a bad idea. However, several felt that, if the patient demanded it, the principle of Autonomy required that it be given. Others noted that this might violate the principle of Non-maleficence. I pointed out that that there were many areas in which we do not allow the patient to pick his/her treatment of choice. For example, we do not allow people to walk into a pharmacy and buy narcotic pain relievers without a prescription, no matter how much they might want them. Certainly the effects of chemotherapy poisons were at least as great.

These are not always easy decisions, but it is one of the reasons being a doctor is hard, respected, and well-paid. If everything were a simple algorithm and one could just memorize the right answer as these medical students were expected to do so often on their multiple-choice tests, it could be done by someone with much less training. Sure, it is possible that someone getting antibiotics for viral sinusitis to get better – indeed they usually do, with our without the antibiotics. Temporal association is not cause. Thus, even when you do the right thing, based on the evidence, and do not get a test or treatment, it is still possible that you will end up worse.

As Eggs and Woody discovered.