By Charles A. Pilcher MD FACEP
June, 2014
Sometimes doing nothing is the best care.
There is an increasing body of medical literature illustrating the limits – and dangers – of excessive testing. Too often our legal system assumes that if a doctor had done just “one more test,” the outcome would have been different. Yes, there are cases like that, but rarely is it the result of simply not doing the test. Most often a bad outcome in such situations is not from “not doing the test,” but rather from failing to consider the possibility that a patient’s symptoms could in fact be the result of a disease that would have been identified by that test. It’s not that doctors are telling patients “you don’t need that test,” explaining their rationale, and making the patient their partner in the care. Rather, it is most often a “cognitive error” by the physician.
Our understanding of this has come from an increasing focus on “evidence based medicine.” We are learning from experience – fortunately – that many of out traditional assumptions about what we physicians do has no basis in good practice. We have more data, more “evidence,” that the way we have always done things is not always best for patients.
“Zebra.” A term familiar to every medical student from the first day of their first clinical rotation. Doctors have been instilled with fear that, unless they consider every possibility, do every test available, and eliminate every uncommon disease – the “zebras” – they will miss the diagnosis. But by definition zebras are far less common than horses. Doctors who are always looking for zebras will expose patients to unnecessary tests, treatments and procedures, and the care of those patients can be worse than no care at all. As Dr. Greg Henry, one of the fathers of emergency medicine, has said, “It is far more likely that a common disease will present in an atypical manner, than for an uncommon disease to present in a typical manner.”
The challenge for the dedicated physician is to find and maintain that balance. And the challenge for the responsible attorney is recognizing the difference between a cognitive error and the failure to test, treat or do a procedure, almost always with the benefit of 20/20 hindsight. Doing nothing may be a sign of good care, not a sign of negligence.
An experience in my own family and two recent articles bring this issue into focus. A brief summary of each:
1. My brother’s father-in-law developed pancreatic cancer at age 86. He was offered all available treatments, up to and including a Whipple procedure (a 7+ hour operation). With the average life expectancy with pancreatic cancer being about 6 months with treatment – and its inherent side effects – he opted to do nothing. He was able to finish his bucket list (with the exception of cleaning out his garage), traveled, spent time with family, and avoided the “cancer industry”as (see below.) He lived 10 months on his own schedule, not one built by his doctors and caregivers.
2. “The $50,000 Physical” by Dr. Michael Rothberg is an article in JAMA, June 4, 2014. Dr. Rothberg describes his 85 yo father’s experience of going from one test to another, one incidental finding to another, then to a procedure, from which he developed multiple serious complications, all because of a suspicion during a “routine physical exam” that he might have an enlarged aorta. Such an exam finding is notoriously inaccurate, according to the US Preventive Services Task Force. Dr. Rothberg explains that, despite the lack of evidence for most parts of any “annual physical,” there is no evidence. But we continue to believe in it. Why? Partly because physicians get paid for it and for the downstream revenue it generates, but because patients expect it, and finally because of physicians’ own anxiety about missing something serious. While it is still worthwhile to visit a physician periodically, monitor overall health, address risk factors, and do those procedures (blood sugar, glaucoma testing, colonoscopy, etc.) that have evidence of value, health professionals, patients and payers must recognize that more is not always better. “[S]erendipitous, life-saving events are much less common than the false-positive findings that lead to invasive and potentially life-threatening tests… Although an examination-free annual visit to a primary care physician may be worth preserving for other reasons, we must admit that this is an untested intervention that may not add value.”
3. In “Incidentaloma Fatigue” in JAMA Internal Medicine, June 2, 2014, Dr. Michael J. Barry amplifies on the above. He describes a patient who presented with some left arm symptoms (which ultimately were successfully treated by a neurologist with a simple course of prednisone) but whose testing in pursuit of the cause of his presenting problem led to a “not-so-merry chase of the multiple incidental findings.” After undergoing 3 ultrasound examinations, 3 CT scans, an MRI, a biopsy, 2 additional specialty consultations, and multiple laboratory tests, nothing requiring treatment was identified and the patient remains well 2 years later. All but one of the findings leading to more tests were outside the area of concern, i.e., incidental findings known as “incidentalomas.” Again, as noted by Dr. Rothberg, “easy availability of imaging tests, the pressure to be thorough in medicine, difficulty tolerating diagnostic uncertainty, medical-legal concerns, and the economics of self-referral for additional radiologic examinations may have all played a role in starting and maintaining the cascade…. My guess is that the real limitation is concern about the medical-legal implications of not following up on incidental findings…But physicians—not lawyers—create the beast that they most fear, the standard of care.” Dr. Barry asks what would happen if all images outside the area of concern were somehow technologically erased to focus only on the area of interest. “Could this approach solve this vexing problem?”
4. Finally, Kathleen Bartholomew RN writes about the “The Cancer ‘Business’” in Health Benefits Insiders, May 7, 2014. She says that “As a nurse I have witnessed some terrible endings. Just when death seemed to offer an imminent relief to suffering, new orders for cancer patients would call for even higher doses of chemotherapy. Many patients were frustrated, robbed of lucid final goodbyes… Eventually, I realized that what we were really infusing through those specially marked IV bags was ‘hope’. The problem was that no one acknowledged that some of these IV bags were filled with ‘false hope’.” Because of this, cancer treatment has become big business with $35 billion per year spent on chemotherapy alone. Bartholomess further describes a recent study in the Boston Medical Journal that found no difference in mortality rates in women receiving mammograms compared to those who received an annual breast exam by a trained nurse. “Even more disturbing was the fact that 20% of the cancers detected by mammography posed absolutely no threat, yet many women underwent unnecessary surgery, radiation or chemo.” She adds that “over-diagnosis and misdiagnosis of cancer are two growing trends that clearly show a lack of standardization and consensus on best practice,” with marked variability of open breast biopsies, ranging from “10% for employed hospital surgeons vs. 35% for surgeons in private practice.” Too many cancer patients receive chemotherapy in their last few months of life, and studies show that hospice patients who avoid such treatments actually live longer with a better quality of life. Bartholomew concludes by saying that “Insisting our physicians be gods of infinite means and magic inadvertently creates demand and disheartened patients and caregivers alike. As long as we continue to ignore perverse financial incentives, misdiagnosis, and unexplained variation in treatments, cancer will rage.”
Another article on overdiagnosis and overtreatment of cancer, by Wegwarth and Gigerenzer, published in JAMA Internal Medicine is available here.
Food for thought.