Are You Getting Too Much Medical Care?

First, do no harm—that’s what medical students are taught. Yet unnecessary drugs and tests, along with overly broad definitions of health conditions, can set you up for unexpected damage  

by Christie Aschwanden
Photograph: Illustration: Brian Stauffer

A few months ago, I went to my gynecologist looking for help with a menstrual problem. She put me in stirrups, and the next thing I knew, I was getting a Pap smear. That wasn’t what I’d come in for, but it had been a year since my last test for cervical cancer, so I went along. After all, catching cancer early is always the goal, right? To my surprise, I later learned that, according to the most recent science, it’s actually possible to catch a cancer too early. And being tested frequently—i.e., every year—was not my best game plan.

Most cervical cancers progress very slowly, and high-quality research has shown that some of the precursors to cancer that a Pap test can detect will go away without medical treatment. Right now, however, there’s no “wait and see” in the system. When the Pap reveals certain abnormalities, the immediate next steps are additional doctor visits, plus invasive and painful testing, says Russell Harris, MD, a professor of medicine at the University of North Carolina at Chapel Hill. This cascade of events saves some lives, but it also needlessly inconveniences and even harms many who were never in danger.

Experts have learned that we can have the best of both worlds: Because cervical cancer is so slow to spread, the Pap test can be done less frequently while still identifying the women who are at risk well within the window of when they can be successfully treated. At the same time, doctors can spare those who are not truly at risk from unnecessary callbacks and biopsies. That’s why most medical groups have called for women to be tested every three years instead of annually (those at high risk are an exception).

A shift in the frequency of Pap tests is only one small facet of a remarkable change taking place in the medical world. This new way of thinking contends that our medical system’s “more is better” mind-set has saddled healthy people with costly treatments that might actually hurt them, says Fiona Godlee, MD, editor-in-chief of the BMJ (formerly the British Medical Journal), a professional publication that’s leading the charge toward a risk-benefit approach to health care. As part of its Too Much Medicine campaign, the BMJ has presented a series of articles outlining how certain conditions, including osteoporosis, dementia, high cholesterol and breast cancer, are being overdiagnosed and overtreated by doctors.

Take osteoporosis. A study published in the BMJ in 2008 calculated that to prevent one woman from developing fractured vertebrae, 270 women with preosteoporosis would need to take osteoporosis drugs for three years. Two out of three of the vertebrae fractures prevented would not have caused symptoms or reduced the patient’s quality of life. So one woman would avoid a consequential fracture in her vertebrae, and the 269 other women would get no measurable benefit but would subject themselves to potential side effects such as diarrhea, an increased stroke risk, gastrointestinal troubles and a rare but very serious problem called osteonecrosis of the jaw, which causes the bone in the jaw to die.

Medical societies are another part of the “more isn’t necessarily better” movement. The ABIM Foundation created the Choosing Wisely campaign, for which 30 physician-specialty societies, such as the American Academy of Family Physicians (AAFP), each developed a list of actions doctors and patients should question. The AAFP list, for instance, includes “Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.” (For more examples, see “Are You Being Overtreated?”. Find each specialty’s Choosing Wisely list at choosingwisely.org.) The lists are intended to spur conversations between doctors and patients so that together they can choose the most appropriate and necessary treatments.

The risks of overtreatment
Unnecessary tests and treatments account for as much as 34 percent of the health care in the U.S., wasting an estimated $226 billion each year, according to a study published last year in the Journal of the American Medical Association. Despite these costs, the movement among medical professionals to reduce overtreatment isn’t simply about money; it’s about protecting patients from the damage that overtreatment can inflict, says Glen Stream, MD, a California family physician who’s a past president of the AAFP board.

The damage isn’t always obvious. Suppose you have a sinus infection. Whatever you do, you’ll probably be fine in a few days, but if your doctor prescribes antibiotics, you may mistakenly attribute your improvement to the pills. Sinus infections almost always arise from a viral infection, which antibiotics are powerless to treat. Taking those antibiotics isn’t just a waste of time and money; they’ll kill off protective bacteria in the vagina, which may spur a yeast infection. The drugs may also leave you more susceptible to antibiotic-resistant infections. So the medicine you’re happy to get may actually hurt rather than help you, says Rosemary Gibson, a health care expert and author of The Treatment Trap.

Yet “despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis,” the AAFP says. Why do physicians continue to follow practices that haven’t been supported by research? “Doctors, like all human beings, are creatures of habit. Our default is to continue on the path we’ve always trod,” says Danielle Ofri, MD, PhD, associate professor of medicine at New York University School of Medicine and author of What Doctors Feel.

A single unnecessary test can start a series of interventions, some unpleasant or even painful, that cost you time, money and peace of mind, says Leana Wen, MD, director of Patient-Centered Care Research at George Washington University and coauthor of When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. Up to 40 percent of imaging tests of the abdomen, pelvis, chest, head and neck spot so-called incidentalomas—findings that look like tumors but are unrelated to the purpose of the test, according to a report in the Archives of Internal Medicine. While a few of these accidental findings do turn out to be cancerous, most are benign. But once an incidentaloma is detected, it may take several more tests (involving more doses of potentially harmful radiation) and multiple trips to the doctor to find out for sure, Wen says. A true cancer will surface eventually, when it causes symptoms.

How cancer screening can hurt rather than help
Cancer has long been seen as a progressive disease that will kill us unless it’s treated in time; hence the drive, over the past few decades, for people to be screened regularly. But that definition of cancer isn’t necessarily accurate, says H. Gilbert Welch, MD, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and coauthor of Overdiagnosed: Making People Sick in the Pursuit of Health. Most people have a few cancer cells inside them, but these will be eliminated by our immune systems before they can cause harm, says Deborah Grady, MD, a professor at the University of California, San Francisco, School of Medicine. Even when cancer cells evade the immune system, they are not always fatal. Autopsies show that many people who die of other causes have undetected cancers that never caused trouble. Yet those cancers would probably have been treated if the person had been screened. In addition, there is the problem of false positives, test results that indicate a tumor is present, triggering further testing, when in fact there is no tumor.

Given these possibilities, health policy makers must weigh the risk of finding—and treating—a cancer that would never hurt you against the risk of missing one that could take your life. For instance, there’s no doubt that the Pap smear has prevented an epidemic of deaths from cervical cancer over the past 50 years, but it also creates many false alarms that needlessly subject women to painful follow-up tests, says North Carolina’s Harris. According to an analysis published in the American Journal of Clinical Pathology, screening every three years instead of annually provides 90 percent of the benefits while reducing the harm by roughly 33 percent. That’s why the current guidelines from the American Cancer Society and other medical organizations state that women ages 30 to 65 need a Pap test every three years, or every five years if they also get an HPV test (for a virus associated with cervical cancer).

Despite this professional consensus, a survey published earlier this year in the American Journal of Preventive Medicine found that most of the 366 obstetrician-gynecologists interviewed continue to recommend annual Pap tests. “Some physicians may have a financial interest in having women come back for yearly Pap tests because it gets them in the door,” says Gibson.

Why we’re being overdiagnosed
Our rush to detect and then treat diseases before they produce symptoms has led to a proliferation of “prediseases,” such as prehypertension, prediabetes and preosteoporosis, that turn healthy people into patients, says the BMJ’s Godlee. The definitions of normal and abnormal are generally created by panels of doctors—but they are sometimes influenced, Godlee says, by pharmaceutical companies that hope to create a wider market for their drugs by expanding the definition of illness to include the worried well.

“By some counts, half of all white postmenopausal women have preosteoporosis. This arbitrary cutoff point pulls in large numbers of women at very low risk of fracture,” says Godlee. “For the drug companies, it’s a gold mine.”      

Doctors want to help their patients prevent serious health problems, but in some cases, this urge to do more exposes patients to risks without much potential benefit. A study reported this year in JAMA Internal Medicine asked more than 200 physicians to read vignettes describing six fictitious patients and decide whether they’d prescribe each patient a cholesterol-lowering statin drug. About 88 percent of the doctors said they would prescribe statins, which can cause serious side effects such as muscle damage, diabetes and liver damage, to patients unlikely to gain any benefits.

Physicians have been taught that delivering care means doing everything they can, which often biases them toward doing something. “It’s always much harder to watch and wait than it is to test, because testing relieves everyone’s anxiety—whether or not it makes you better,” says Lisa Schwartz, MD, a professor at Dartmouth Medical School and coauthor of Overdiagnosed.

Another major culprit in overdiagnosis is the way we pay for health care, says Gibson. “Hospitals and doctors are paid more for doing more,” she says. “No one makes money when they decide to watch and wait.” Sometimes doctors have financial reasons for favoring drug treatment or a medical device. ProPublica’s “Dollars for Docs” investigation has documented pharmaceutical incentive programs that give doctors generous monetary rewards for prescribing a company’s drugs.

And then there is “defensive medicine,” aka doctors’ fear of being sued for malpractice if they don’t do everything they possibly could. “You’re sued for not doing something, but you’re rarely sued for doing too much,” Schwartz says. In a survey published in the -Archives of Internal Medicine in 2011, 76 percent of the physicians surveyed said malpractice fears drive doctors to treat their patients too aggressively.

Talk with your doctor
To avoid medical care you don’t need, start a discussion with your doctor. “Medical recommendations are often wrapped together with value judgments,” says Peter Ubel, MD, a physician, behavioral scientist and author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. Which is more important to you: having a label for what ails you or avoiding unnecessary tests that may cost you time, money and worry? Are you willing to adopt healthier lifestyle habits if that allows you to avoid taking a drug? Share your preferences with your doctor. “A patient who can put her values on the table is at an advantage here,” Ubel says.

If possible, do some research before your visit and arrive with a Choosing Wisely list or similar information in hand to help you get the conversation started. Before you agree to a medical test, Wen says, ask your doctor, “What’s this test looking for, what will happen if it’s positive or negative, and how will the results change what we do?” Other important questions, Wen says, include, Is there an alternative to this test? What can we do to lower the risks? Are there tests other than CT scans that can reduce my exposure to radiation? “Every test should be ordered for a specific reason,” Wen says. “If the doctor can’t tell you why he or she is ordering the test, that’s a red flag.” Bottom line: You have the right to refuse any test or treatment you don’t want.

A good doctor listens with her full attention. “Your history, which is your story, can lead to the right diagnosis 80 percent of the time; that’s why telling your story is so important,” Wen says. “Tell your doctor, ‘I believe I’m the expert when it comes to my body, and you’re the expert when it comes to medicine, so let’s work together to figure out what I have.’ ”

I won’t be going back to the doctor who gave me the unnecessary Pap test, but if my next doctor repeats the mistake, I intend to borrow a script that Harris suggested: “I’ve read a lot about this, and not everyone agrees with what you’re recommending. This test has both pros and cons; it’s not compulsory.” If the next doctor won’t listen to my concerns, I’ll keep searching until I find one who does.

Next: The New Science of Living Longer

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First Published Wed, 2013-10-30 12:19

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