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. 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.
How frequently are patients receiving too many tests or treatments?
A survey of US primary care doctors found that 42% believe their own patients are receiving 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.
But what about too many tests and treatments for healthier people? Unfortunately, seemingly healthy people, including those with non-life-threatening illnesses, receive too many test and treatments as well.
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.
What makes this problem even worse? Sometimes doctors recommend treatments that are unproven or ineffective (for more information, read my post Should You Trust Your Doctor’s Recommendations?).
Why are primary care doctors prescribing too much medical care?
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.
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
What role are patients playing?
Patients influence some of this unnecessary spending by asking doctors for unneeded medical services. The survey of primary care doctors (PCPs) also examined patients’ role in over testing and over treating. The findings include:
- About 52% of the PCPs reported they had made referrals to specialists based on patients requests, even though the doctors felt the referral wasn’t necessary.
- At the request of patients, 38.7% of the PCPs prescribed brand-name medications to patients when a generic was available.
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.
Doctor-Owned Surgical Centers
Your doctor might encourage you to have a procedure because he/she has a financial incentive to recommend it or perform it. An analysis by The National Bureau of Economic Research evaluated 12 years of data in Florida. They looked at the frequency of a common knee procedure to treat osteoarthritis which had recently been found to not improve outcome during a major clinical trial. The research found that doctors who worked in doctor-owned surgical centers, who have financial incentive to perform the procedure, did not have as much of a decline in the number of these surgeries performed as compared to doctors who were not part of doctor-owned centers. This suggests that when doctors have a financial incentive, they may perform procedures that are not in the best interest of the patient.
What can you do?
To reduce your risk of receiving too many tests or treatments, consider my suggestions:
Get the most out of your doctor appointments!
- 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.
- Ask your doctor as many questions as you need to be sure you understand your diagnosis (or list of possible diagnoses), tests, procedures and treatments. If you do not understand a response, do not be shy about asking the question again.
- 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.
- Ask your doctor for a list of possible diagnoses, even if he/she feels certain about the suggested 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 make informed decisions when they have a complete picture of patients’ health, including other diagnoses, medications and treatments.
- Get a 2nd opinion, or even a 3rd opinion, preferably from a doctor at a different practice/hospital. When speaking with a new doctor, be sure to tell the doctor your story. Don’t let him/her rely on notes from other doctors.
- 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 info, read this blog post: Can You Trust Advice from Other Patients?
- If something doesn’t seem right, speak up!
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?
If possible, don’t make quick decisions.
- 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 doesn’t seem right.
- Think carefully before insisting on a test or treatment. Of course, 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.
- Get a second opinion – it’s always helpful to have another perspective. For more information, read: Why are Second Opinions Important?
Receive 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:
- 10 Tips for a Better Medical Appointment
- Patient-Doctor Communication is a Key to Good Health
- Should You Record Conversations with Your Doctors During Your 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
NOTE: I updated this post on 5-5-20.