Lindsey Tanner, AP
Too much cancer screening, too many heart tests, too many cesarean sections. A spate of recent reports suggest that too many Americans — maybe even President Barack Obama — are being overtreated. Is it doctors practicing defensive medicine? Or are patients so accustomed to a culture of medical technology that they insist on extensive tests and treatments? A combination of both is at work, but now new evidence and guidelines are recommending a step back and more thorough doctor-patient conversations about risks and benefits.
As a medical journal editorial said this week about Obama's recent checkup, Americans, including the commander-in-chief, need to realize that “more care is not necessarily better care.”
President Obama’s exam included prostate cancer screening and a virtual colonoscopy. The PSA test for prostate cancer is not routinely recommended for any age and colon screening is not routinely recommended for patients younger than 50. President Obama is 48.
The colon exam exposed him to radiation “while likely providing no benefit to his care,” Dr. Rita Redberg, editor of Archives of Internal Medicine, wrote in an online editorial. “People have come to equate tests with good care and prevention,” Redberg, a cardiologist with the University of California at San Francisco, said in an interview.
This week a New England Journal of Medicine study suggested that too many patients are getting angiograms — invasive imaging tests for heart disease — who don't really need them; and specialists convened by the National Institutes of Health said doctors are too often demanding repeat cesarean deliveries for pregnant women after a first C-section. Last week the American Cancer Society cast more doubt on routine PSA tests for prostate cancer. Other groups have recommended against routine mammograms for women in their 40s, and for fewer Pap tests looking for cervical cancer.
Experts dispute how much routine cancer screening saves lives. It also sometimes detects cancers that are too slow-growing to cause harm, or has false-positive results leading to invasive but needless procedures — and some risks. Treatment for prostate cancer that may be too slow-growing to be life-threatening can mean incontinence and impotence. Angiograms carry a slight risk for stroke or heart attack.
Not all doctors and advocacy groups agree with the criticism of screening. Many argue that it can improve survival chances and that saving even a few lives is worth the cost of routinely testing tens of thousands of people.
Doctors also often order tests or procedures to protect themselves against lawsuits and also because the fee-for-service system compensates them for it, said Dr. Gilbert Welch, a Dartmouth University internist and health outcomes researcher. Some doctors think “it's always a good thing to look for things to be wrong,” Welch said. It also has become much easier to order tests — with the click of a mouse instead of filling out forms, and both can lead to overuse, he said.
While many patients also demand routine tests, they're often bolstered by advertisements, medical information online — and by doctors, too, Welch said.
Jennifer Traig, an Ann Arbor, MI author of a book about hypochondria, says patients like her often think, “I'm getting better care if we're checking for more things.” Traig has had many costly high-tech tests, including an MRI and several heart-imaging tests, for symptoms that turned out to be nothing. She thinks doctors were right to order those tests, but that counseling could have prevented her from wasting resources and getting tests it turned out she didn't need.