Respectful Insolence

Choosing Wisely when it comes to medicine

Over the years, I’ve written a lot about overdiagnosis and overtreatment. Basically, overdiagnosis is the diagnosis of a condition that, if left untreated, would very likely never cause the patient harm. Because I’m a cancer surgeon, I’ve almost always written about overdiagnosis in the context of–you guessed it–cancer, particularly breast cancer. In breast cancer, for instance, it’s been estimated that as many as one in three cancers diagnosed by screening mammography might represent overdiagnosis. Personally, I think that particular study overestimated the rate of overdiagnosis, but there is little doubt that overdiagnosis is a significant problem in breast cancer. The reason is that too much screening leads to overdiagnosis, and overdiagnosis leads to overtreatment. When we diagnose that tiny focus of ductal carcinoma in situ, even though it probably wouldn’t hurt the patient we don’t know that for sure, which means that it gets treated with surgery at minimum, plus possibly radiation and antiestrogen therapy. There are many other examples in other diseases.

If screening tests are a problem, there are also a bunch of tests that are ordered too frequently or for dubious indications. The reasons can range from laziness to defensive medicine, but whatever the reason they’re ordered such tests cost money, can lead to incidental findings that need further workup, and can even lead to overdiagnosis. In 2010, Dr. Howard Brody published a challenge to his physician colleauges in The New England Journal of Medicine. It was an amazing article, in which Dr. Brody challenged physician specialty organizations thusly:

In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty’s “Top Five” list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.

Amazingly, some specialty organizations have done just that. It’s amazing, but true. In an initiative called Choosing Wisely, nine specialty societies have produced lists of Five Things Physicians and Patients Should Question, which Choosing Wisely describes as “evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation.” Naturally, being a cancer surgeon, I went straight for the recommendations made by the American Society of Clinical Oncology (ASCO). Interestingly, two out of the five recommendations were breast cancer-related:

  • Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
  • Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.

It’s true. Far too often we do a million-dollar workup for patients with early stage breast cancer, and there is pretty much zero good evidence that these workups improve survival, improve care, or otherwise do anything except cost a lot of money, delay definitive treatment, expose the patient to radiation, and provoke worry in both patient and practitioner. I realize this is anecdotal experience, but overuse of these tests in early stage breast cancer doesn’t appear to as much of a problem in big cancer centers as it does in community cancer hospitals. But it is a problem in a lot of places.

One thing that actually surprised me was that the Choosing Wisely list from the American College of Radiology didn’t appear to include any breast cancer-related recommendations. For instance, routine breast MRI before surgery for breast cancer doesn’t decrease the rates of needing reexcision. On the other hand, it’s refreshing to see a recommendation that most surgeons instinctively know to be true:

Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

Of course, although doctors carry a large share of the responsibility for unnecessary tests, medications, and care, they are not alone in being responsible for the overuse of various medical tests and interventions. The classic example, of course, is the use of antibiotics for viral infectious, which is something that patients often demand in the mistaken belief that it will help them and that many doctors use because patients ask for it and it’s easier to give in than to spend the time it takes to explain why it’s not medically indicated. Another contributor to the problem is that many of these tests have a significant financial incentive:

Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately.

“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ “

Then there’s the Ayn Randian “super doctor” syndrome, such as that displayed by the Association of American Physicians and Surgeons (AAPS), in which all too many physicians view any evidence-based guidelines as threats to their autonomy, disparagingly referring to them as “one size fits all” and viewing them as “cookbook medicine.” Choosing Wisely is a good start towards making medicine more evidence-based, but I’ll be shocked if there isn’t some skepticism and resistance. Old habits die hard, particularly when some of them make doctors money.