Physician Focus: Medical tests: What do you need?
By Michael Barry, M.D.
More is better has been a common theme in American medicine for years, as patients have been urged to get annual checkups and periodic screenings at certain stages of life. Such exams have long been considered key steps to sound medical health, offering prevention against illness and disease.
Recent studies, however, have challenged the value of some of these exams, and the question of what tests patients should get has now become an important and controversial topic, with researchers saying that many tests have no effect on reducing disease or death and in some cases cause harm.
American medicine is reaching the conclusion that more isn's always better. The U.S. Preventive Services Task Force, an independent panel of experts that issues recommendations for preventive services in primary care, has advised against a number of common preventive health measures tests, and the ABIM Foundation's campaign, Choosing Wisely, supported by many medical specialty groups, encourages discussions between physicians and patients to select tests and treatments that are based on clinical evidence, free of harm, and don's duplicate other tests.
For most medical problems, there is more than one reasonable way to proceed, yet too often patients make decisions without a thorough understanding of their options. The trend today is for patients to have a voice in those decisions, and the concept of shared decision-making, which allows the physician and patient to decide together what tests and treatments are best, is becoming more common and accepted.
The notion that we test and treat too much isn's new to health care in America. Some patients, for example, ask for an expensive imaging test to be sure the headache they'se having isn's a brain tumor. Others ask for antibiotics in situations where those medicines will have no effect. Many physicians admit to practicing “defensive medicine” — ordering tests and treatments to protect themselves from malpractice lawsuits.
More attention to the frequency and kinds of testing and treatments patients are undergoing has come about because of soaring health care costs, but the concern is more than just about spending too much: it's also about causing harm.
Each test or treatment can have potential negative effects as well as positive ones. The PSA test for prostate cancer is a good example. The reliability of the test has been called into question, and while the test can detect cancers, many of them it does spot may not be harmful. A patient could live with prostate cancer for years, even decades, without harmful effects, but PSA findings can lead someone to decide on surgery or radiation that can have considerable long-term side effects. False-positive mammograms, raising the initial suspicion of breast cancer later dispelled with additional testing, is another example.
Shared decision-making is intended to give the patient a voice in health care decisions, so that good medical decisions are made with the full participation of informed patients. I encourage patients to speak up, to take an active part in their care, because, ultimately, they are the ones who have to live with the consequences of their decisions.
To help patients become more informed, the Informed Medical Decisions Foundation has, in concert with Health Dialog, developed patient decision aids, so patients can participate more fully with their providers. Among the aids are those addressing heart disease, chronic conditions, breast cancer, mental health, and health care screening and testing.
But what about the physician, many of whom feel rushed and don's have the time they's like to have to talk to patients? I suspect many of my colleagues want to give more time to patients; indeed, most surveys indicate that the inability to devote more time to patient care is one of the physician's biggest frustrations.
Shared decision-making is a two-way street. Just as I urge patients to be part of the process, I urge physicians to invite their patients into conversation. A key part of the physician-patient relationship is the physician learning what patients care about and what their preferences are. And it's okay if the either the patient or physician takes the first step to make that happen.
For more information, visit http://informedmedicaldecisions.org/ or www.ChoosingWisely.org. For a video discussion, visit www.physicianfocus.org/checkups.
Michael Barry, M.D. is President of the Informed Medical Decisions Foundation in Boston and Medical Director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital. Physician Focus is a public service of the Massachusetts Medical Society. Readers should use their own judgment when seeking medical care and consult with their physician for treatment. Send comments to PhysicianFocus@mms.org. ??
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