Have you ever insisted on a test or treatment when your doctor suggests otherwise? Has your doctor pressured you to get tested, or undergo a treatment, that you didn’t think was needed? The dangers of too many tests and treatments for patients should be of concern to all of us as it can impact our health and our wallets.
I know I have insisted on testing – and sometimes it’s been well justified upon finding an issue that needed treatment – and sometimes it’s turned out to be a waste of time and resources. On the other side of the equation, doctors may insist on tests or treatments that might not be in the best interest of the patient. I have been on the receiving side of that equation and it was time-consuming, expensive, and unpleasant.
Why is too much medical care so bad?
All medical tests carry some degree of risk, including side effects, false positives, and false negatives. Additionally, everyone has some abnormalities that would turn up with enough probing, so increased testing can lead to increased treatments. Moreover, all procedures, treatments and medications carry some degree of risk and a price tag. Furthermore, unnecessary invasive procedures can lead to mental distress, physical harm, or death.
Simply put, too many tests and treatments are not good for patients or our collective wallets. This is especially a concern for tests involving radiation, particularly CAT scans, since exposure to radiation is dangerous in cumulative doses.
How do unneeded treatments impact spending?
Researchers estimate that 30% of annual US healthcare spending could be unnecessary, including “avoidable hospitalizations, unnecessary procedures and testing” and unneeded medications.
Why do doctors prescribe too much medical care?
There are many reasons why doctors order too many tests and treatments.
For starters, in the quest for a diagnosis, doctors may order tests “just to be sure” and to “rule things out”. At the same time, patients ask for tests to give them the peace of mind that nothing serious is wrong, and/or ask for medications or procedures in the hopes of feeling better. Combine these factors with the brief time allotted for appointments, and it’s easy to see why patients are getting medications, tests, and procedures they do not need.
Additionally, as noted below, some doctors and hospitals ignore, or don’t know about, evidence that shows that some treatments are often unneeded.
Finally, and sadly, some doctors order tests and treatments because they gain financially. We’d like to think all doctors have their patients’ wellbeing as their number one priority, but unfortunately that is not always the case. In fact, research shows that doctors who have an ownership stake in surgical centers are more likely to recommend surgical procedures.
Here are a few examples where doctors caused patient harm with unnecessary procedures:
- A Louisiana doctor performed unnecessary cardiac catheterizations and stents, angiograms, and angioplasties on approximately 310 patients over at least 5 years. Sadly, one patient died, and hundreds suffered harm.
- A Florida ophthalmologist misdiagnosed patients with wet macular degeneration to justify unnecessary laser eye surgery. As part of his scheme, he falsified patient records and ordered unnecessary diagnostic tests to support his fake diagnoses.
- A South Dakota surgeon repeatedly performed medically unnecessary spinal surgeries for his own financial gain, resulting in patient injury and death. Although medical staff and former patients/families filed complaints, he continued to practice for many years.
How often do patients receive too many tests or treatments in hospitals?
Far too often! In fact, a 2021 report from the Lown Institute states that “every 80 seconds, a hospital in the US delivers a low-value test or procedure to an older adult, putting hundreds of thousands at risk of harm.”
Furthermore, the Lown Institute’s research found that nationwide, 64% of hysterectomies, 44% of carotid endarterectomies, and 24% of coronary stent procedures met criteria for overuse (unnecessary treatment). These 3 procedures, plus 9 others, are commonly regarded as unnecessary, yet doctors still perform them regularly throughout the US.
Interestingly, some hospitals do a better job than others in reducing the use of unneeded tests and treatments. Why? According to the Lown Institute president, it seems that some hospitals have a culture that either ignores or doesn’t know about the evidence that shows many procedures are not useful.
How often do primary care doctors order too many tests and treatments?
Additionally, a survey of US primary care doctors found that 42% believe their own patients receive too much care; in contrast, only 6% said their patients were receiving too little. That’s a lot of doctors who think their patients get too many tests or treatments!
Of course, it’s not only primary care doctors who are prescribing too much medical care. Many patients close to death receive aggressive, expensive treatments, which may prolong life a bit but may also prolong suffering.
It’s not just very sick people who undergo too many tests and treatments.
Unfortunately, seemingly healthy people, including those with non-life-threatening illnesses, receive too many test and treatments as well.
For example, a study in JAMA Internal Medicine analyzed the data of 240 million adult visits to an Emergency Room. They found that many patients with non-urgent health issues were given diagnostic tests, procedures (like IVs), and were admitted to the hospital, including some to a critical care units, even though these services may not have been necessary.
Doctors over diagnose cancer.
Cancer is scary. Learning you have cancer is some of the worst news you will ever hear in your lifetime. But what if you were told you had cancer, received treatments, and later found out those difficult treatments weren’t needed?
In a recent STAT article, a doctor describes his experiences screening seemingly healthy patients for cancer. He and his colleagues discovered that for some cancers (cancers of the breast, prostate and thyroid, as well as melanoma), the number of patients diagnosed with these conditions is a function of how thoroughly they are examined. Meaning, the harder the doctors look for cancer, the more cancer they find. They found that affluent Americans were at a particularly high risk of receiving cancer diagnoses – because they receive thorough examinations – yet the death rates among the affluent from these cancers are similar to everyone else.
An analysis of breast cancer diagnoses in northern California drew similar conclusions. The women with the highest socioeconomic status were roughly 2x more likely to receive a breast cancer diagnosis, even after controlling for a range of other risk factors.
Why is this happening?
As science advances, the ability to detect cancers has improved. Sophisticated testing can find cancers when they are very small; in many cases these may never grow over time. These tests are sometimes identifying cancers that would never have impacted a patient’s health!
What about other specialists?
It is safe to say that across-the-board doctors of all types are sometimes guilty of overtesting and overtreating. Whether it’s abnormal arteries, bulging discs, or in my case anemia of unknown origin, technology is allowing doctors to thoroughly test patients, and fear of missing something is encouraging this behavior – for patients and doctors.
Additionally, there is a lot of money at stake here. Even though more and more doctors recognize the issue of prescribing too much medical care, many feel trapped in a system that rewards them financially for doing more. And some doctors struggle to fight the traditional thinking that more medical care is better.
What do doctors say about too many tests and treatments?
Interestingly, a 2014 report from Choosing Wisely illustrates doctors’ opinions on this topic:
- 75% of doctors think unnecessary tests and procedures are a serious health care issue.
- 93% feel they have a responsibility to help their patients avoid unneeded tests.
- 47% say patients ask them for unnecessary tests and procedures at least once a week.
- 53% state they perform unneeded tests and/or treatments when patients are insistent.
- Doctors frequently order unnecessary tests and treatments to reassure themselves that they are on track with a diagnosis.
Additionally, a survey of primary care doctors uncovered the factors doctors identified as leading them to practice more aggressively:
- 76% – malpractice concerns.
- 52% – clinical performance measures.
- 40% – inadequate time to spend with patients.
This survey also identified some other interesting factors:
- The doctors stated they felt financial incentives to encourage aggressive practice – 62% said diagnostic testing would be reduced if it did not generate income for medical subspecialists.
- 95% think doctors vary in how they approach care for identical patients.
How do patients influence doctors’ behavior?
Patients influence some of this unnecessary spending by asking doctors for unneeded medical services. For instance, in the survey of primary care doctors (PCPs), 52% of the PCPs reported they had made referrals to specialists based on patients’ requests, even though they felt the referral wasn’t necessary.
What can you do to reduce your risk of too many tests or treatments?
Fortunately, there are steps you can take to reduce your risk of receiving too many tests or treatments.
See how your hospital ranks for unneeded procedures.
It turns out that doctors at some hospitals are more likely than others to order unneeded tests or treatments. Fortunately, the Lown Institute Hospitals Index ranks US hospitals based on overuse criteria to rate their success at avoiding tests and procedures that offer little to no benefit to patients. Check out their lists of the worst 50 and best 50 hospitals ranked by how frequently their patients had any of 12 procedures largely regarded as unnecessary.
Interestingly, it’s generally not the “elite” hospitals that ranked the best for avoiding unneeded procedures. In fact, the Lown Institute’s research found that only one hospital (The Cleveland Clinic) from the current U.S. News & World Report honor roll made their list of the top 100 hospitals for avoiding overuse.
Actively participate in diagnostic and treatment discussions!
It’s critical that you actively engage in the process of determining a diagnosis and choosing treatments. Your input can help you avoid unneeded tests and treatments. How? Read below…
Get the most out of every doctor’s appointment.
- Prepare for medical appointments by writing out a detailed version of your “story”. When did the issue begin? What does it feel like? How is it impacting your life? Have there been any changes in your behavior, location, eating habits, etc.?
- Share your whole story with your doctor, even if you the doctor interrupts you, at every medical appointment. Importantly, don’t get tired of repeating the same information to multiple doctors.
- Ask your doctor as many questions as you need to be sure you understand your possible diagnosis, tests, procedures, and treatments. If you do not understand a response, do not be shy about asking the question again.
- Ask your doctor for a list of possible diagnoses, even if he/she feels certain about the suggested diagnosis.
- If the diagnosis doesn’t make sense to you, discuss this with the doctor. Ask if your story “fits” with the diagnosis, and if not, ask for an explanation of the symptoms that don’t “fit” the diagnosis.
- Take notes at your doctor appointments and bring these notes, and all records, with you every time you will see a doctor, including the Emergency Room. Doctors can only make informed decisions when they have a complete picture of patients’ health, including other diagnoses, medications, and treatments.
- Importantly, if something doesn’t seem right, speak up!
- Think carefully before you insist on a test or treatment. Clearly, there will be times where you need to insist on a test or treatment, but there will also be times where you might be pushing for unnecessary care.
- If you speak with other patients, or read internet sites, discuss your findings with your doctor. However, realize that every patient’s circumstances are different, and some things you read on the internet are not accurate. For more information, read Can You Trust Advice from Other Patients? and Can you Trust Medical Information Online?
Ask questions before agreeing to a test.
- What does he/she expect to learn from the test?
- How will the test results impact diagnosis and treatment?
- What are the risk factors of the test?
- If the risks seem high, are there any alternative ways to get a diagnosis?
- What would happen if you did NOT do the test?
Learn about your treatment options before making a decision.
- What are the recommended options? Why?
- What do other hospitals and facilities offer?
- Are there other options?
- How will the recommended treatment impact my prognosis?
- What are the short and long-term possible side effects?
- What if I take a “wait and see” approach?
- Any alternative medicine treatments to augment traditional treatments?
- Find out if your doctor recommending a treatment that is generally considered unnecessary. You can consult Washington’s Health Alliance list of 47 common treatments known by the medical community
to be overused (see pages 23-25). You can also check out the list of 12 generally unnecessary treatments included in the Lown Institute research. Importantly, sometimes these treatments are necessary and important. However, if your doctor recommends a treatment on these lists, ask your doctor why.
- If your doctor is recommending a surgical procedure at a surgical center (as opposed to at a hospital), ask him/her if they have an ownership stake in the center. Clearly, this can be an awkward question to ask. However, you want to make sure that financial incentives are not influencing the doctor’s recommendations. If you learn your doctor has financial incentives, get a second opinion.
Whenever possible, take time to make a decision.
- Realize you have the right to refuse any test or treatment.
- Don’t be afraid to contact the doctor’s office after you have left if you later feel that the diagnosis or treatment plan doesn’t seem right.
- Take your time to think through your treatment options. Discuss your options with your other doctors, as well as with trusted friends and/or family members.
- Research your condition and possible treatment options online. However, realize there is plenty of fake or misleading information online. Look at reputable sites, such as sites run by Mayo Clinic, Johns Hopkins Medicine, and Merck Manual, and on the US government’s MedLine Plus. You can find reliable information on medications on the US government’s sites DailyMed and Drug Information Portal. For more information, read Can you Trust Medical Information Online?
- Get a second, or even third, opinion. It’s always helpful to have another perspective. Try to find a doctor at a different practice/hospital. When speaking with a new doctor, be sure to tell the doctor your whole story. Don’t let him/her rely on notes from other doctors which can be biased or incomplete. For more information, read Why are Second Opinions Important?
Take advantage of the helpful information from Choosing Wisely.
Visit the Choosing Wisely website and/or download their free app for information that will help you choose care that is:
- Supported by evidence.
- Not duplicative of other tests or procedures already received.
- Free from harm.
- Truly necessary.
For an interesting perspective on this topic by a doctor, read The Washington Post article: How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good.
For more information to help you get the correct diagnosis and treatment plan, read my blog posts:
- How to Choose a Hospital.
- Should You Trust Your Doctor’s Recommendations?
- 10 Tips for a Better Medical Appointment.
- Patient-Doctor Communication is a Key to Good Health.
- Should You Record Medical Appointments?
- Being an Engaged Patient Can Help You Get the Best Medical Care Possible.
- 10 Steps to Reduce Your Risk of Diagnostic Error.
- What are Doctors Doing to Reduce Diagnostic Errors?
- Help for Hard to Diagnose Health Issues.
- Learn a Lesson From Serena Williams: Trust Your Instincts When it Comes to Your Health.