You go to see your doctor for a medical problem and your physician orders some tests. Too many tests, it turns out. The people who pay the bills for health care are starting to take notice of the cost. When it comes to your health, more tests aren't necessarily better.
Generally, it's the people who pay the bills who first noticed this phenomenon. Hospitals that are dealing with deficits start looking for ways to cut costs. It doesn't take long to notice an up tick in certain blood tests, x-rays and CT scans. In the U.S., the Centers for Medicare and Medicaid Services is starting to measure the rates at which doctors and hospitals order tests and has noticed patterns that clearly indicate what appear to be irrational rates of testing.
Anyone who says they don't see it is kidding. I see it all the time. When patients arrive in the ER, we order a panel of what we call 'routine' blood tests. The tests are bundled together which means we don't pick and choose which ones we want. More than half the time, I barely glance at half the results because they're irrelevant to the reason why the patient came to the ER. There are also special tests we order more than we need to. For instance, in the ER, we often order a troponin level - a highly sensitive test that detects the tiniest of heart attacks - even when we don't really think the patient had one. We have another blood test called d-dimer that helps us rule out a blood clot on the lung. There are many instances in which we order that particular test not because we really want to rule out a blood clot but because the chart will look better in retrospect if we ordered it. I think a lot chest x-rays are unnecessary. A smaller but still significant number of CT scans are unnecessary too.
A survey in the Archives of Internal Medicine found that ninety percent of physicians in the US over-test to avoid lawsuits.
One doctor I know failed to order a PSA test for prostate cancer at a patient's annual physical. Sure enough, several months later, the patient was diagnosed with incurable prostate cancer, sued the doctor, and won. It's entirely possible that had the doctor ordered a PSA at the physical, the cancer would have been found to be incurable at that point as well. Now, the doctor doesn't even think about it - he just orders PSAs on every man.
A survey presented at a recent meeting found that 20% of CTs and MRIs ordered by orthopedic surgeons are done for defensive reasons.
Even if you aren't sued, if the patient dies and you're shamed at Morbidity and Mortality rounds, you generally start ordering lots more tests. Another reason for over-testing: new doctors can't function without them. Twenty years ago, a surgical resident spent time carefully examining a patient to help decide if he or she needed a CT. Now, many surgeons, especially the younger ones, won't even see a patient until the CT is complete. Testing has become more of a reflex than a higher-level decision. In some cases, we're over-testing because experts keep lowering the criteria for diabetes and cholesterol. Slight elevations in either that wouldn't have raised an eyebrow ten years ago are now subjects for over-testing.
Over-testing using CT scans - especially CTs of the abdomen - exposes the patient to high doses of radiation. That increases the risk of cancer down the road.
Sometimes, over-testing leads to over-diagnosis and over-treatment. That's something Gilbert Welch and colleagues talk about in their new book 'Over-Diagnosed'. Welch talked about a patient of his who had a slightly elevated blood sugar. Per new guidelines, Welch prescribed pills to bring the slightly elevated blood sugar to as near normal as possible. As often happens, the doctor overshot and the patient had an episode of very low blood sugar in which he had a car accident and broke two vertebrae in this neck. Over-testing leads to needless anxiety among patients. And unnecessary surgery. And it drives up the cost of medicine. In the US, it's been estimated that defensive medicine costs the system tens of billions of dollars.
You may be tempted to blame well-read and well-googled patients who expect lots of tests. When Oprah did a show on total body CT scans, I have no doubt she drove requests for that unnecessary and potentially dangerous bit of testing through the roof. I think shows like House may encourage patients to think that more tests means better care. On the other hand, it's possible that people see House as a caricature rather than a role model. I think it's more likely that over-testing is being driven by the doctor and not by the patient. Given that, I think it's fair game for patients to ask the doctor to justify each and every test. If they can't, then maybe they don 't need to order it in the first place. But with the power to ask comes responsibility. If you want to question your doctor and are satisfied with their response, then don't second-guess then a year later when things don't turn out so well and you wish the doctor just did the test!