Experts say US doctors overtesting, overtreating

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Experts say US doctors overtesting, overtreating

By Lindsey Tanner, Ap Medical Writer –

CHICAGO – 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. "

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. Obama is

48.

Earlier colon cancer screening is sometimes recommended for high-risk groups —

which a White House spokesman noted includes blacks. Doctors disagree on whether

a virtual colonoscopy is the best method. But it's less invasive than

traditional colonoscopies and doesn't require sedation — or the possible

temporary transfer of presidential power, the White House said.

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. Obama's experience " is multiplied many times over " at a

huge financial cost to society, and to patients exposed to potential harms but

no benefits.

" 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 Thursday. " Prevention is all the things your mother told you — eat

right, exercise, get enough sleep, don't smoke — and we've made it into getting

a new test. "

This week alone, 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. And a few months ago, other groups 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.

Dr. Pronovost, a s Hopkins University patient safety expert, said

routine testing is often based on bad science, or on guidelines that quickly

become outdated as new science emerges.

The recent shift in focus reflects evolving research on the benefits and risks

of screening.

While some patients clearly do benefit from screening, others clearly do not,

said Dr. Wender, former president of the American Cancer Society.

These include very old patients, who may unrealistically fear cancer and demand

a screening test, when their risks are far higher of dying from something else,

Wender said.

" Sometimes it's kind of the path of least resistance just to order the test, " he

said.

Doctors also often order tests or procedures to protect themselves against

lawsuits — so-called defensive medicine — 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.

" To some extent we've taught them to demand these things, " he said. " We've

systematically exaggerated the benefits of early diagnosis, " which doesn't

always improve survival. " We don't always tell people there might actually be

downsides " to testing.

Traig, an Ann Arbor, Mich., 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.

Patients seeking screening information have several online resources, including

the National Institutes of Health, http://bit.ly/a8c7P0; the American Cancer

Society, http://bit.ly/9w0fli; and a nonprofit advocacy group called the

Foundation for Informed Medical Decision Making,

http://www.informedmedicaldecisions.org.

The new guidance from the cancer society last week on PSA testing, echoing

others' advice on mammograms, is for doctors and patients to thoroughly discuss

testing, including a patient's individual disease risks, general pros and cons

of testing and possible harms it may cause.

Dr. Bruce Minsky, a University of Chicago cancer specialist who still favors

routine mammograms for women in their 40s, said that emphasis is a positive

trend.

" That to me is one of the greatest benefits, " he said. " It enhances that

communication between the physician and patient. "

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