Wednesday, September 12, 2018

Is More Medical Testing Better?

“I think this patient needs a CT scan of her chest,” the consulting physician said to me over the phone. “Her lungs sound bad, and given her history, we need to make sure she isn’t developing pneumonia.”

The patient, though only thirty-five, had been through a lot during her hospitalization. She came in a week prior with some shortness of breath, an abnormally high heart rate (tachycardia) and chest pain. But her heart checked out just fine. An EKG was normal and her troponin, a protein that spills into the blood with damage to heart, was undetectable. Because of her tachycardia and chest pain we tested her for a pulmonary embolus, or clot in the lungs, with a CT scan. It was positive. The potentially deadly clot blocks off blood flow coming from the right side of the heart into the lungs causing heart strain and disrupting oxygenation of blood and the functioning of the heart.

We admitted the patient to the intensive care unit where she received IV medication to thin her blood. She recovered but continued to experience residual chest pain that would clear in the months ahead. As we prepared to discharge the patient, the consulting physician, a cardiologist, told us he wanted her to get another CT scan of her chest. She had not had a scan since the initial stages of her workup. What if she developed pneumonia in the interim? Her white blood cell count, often a crude marker of infection, was not elevated. She did not have fevers. When asked, she felt well enough to go home and wanted to leave. Then again, being in the hospital made her susceptible to infection. Moreover, on her physical exam, we heard crackles in her lungs – this sometimes indicates an intrapulmonary pathology. The cardiologist’s concern gave us pause and we ordered the imaging study.
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Doctors often feel uncomfortable with areas outside of our expertise. Consequently, we call other specialists to see the patient and give us advice. Moreover, patients sometimes ask to see a specialist in the hospital: “Can you call the neurologist to come see me?” or “We’d like you to call a cardiologist to see our father while he’s here.” Because consultants share a different knowledge base than the team primarily caring for the patient they may ask for more tests to rule out other serious pathologies that the primary team neglected to consider.

The patient’s repeat CT scan merely demonstrated small collapsed alveoli. These terminal branches of the lungs often collapse when we draw shallow breaths or lie flat for a long time, a typical finding in many hospitalized patients. Given the benign nature of this finding, we discharged the patient. Yet she had received an extraneous dose of radiation and her hospital bill would be hundreds of dollars more. Did she absolutely need this? This common story raises other questions, too. Do patients do better with more specialists seeing them? Do patients do better with more testing?

In a 2012 post for the New York Times Well blog, Tara Parker-Pope pointed out that “overtreatment – too many scans, too many blood tests, too many procedures – is costing the nation’s healthcare system at least $210 billion a year, according to the Institute of Medicine.” And the stories she tells about astronomical hospital bills due to overtesting are disturbing.

In a 2015 article in the Journal of the American Medical Association, a group of researchers found mortality for high-risk heart failure and cardiac arrest among patients was lower in teaching hospitals during national cardiology meetings compared to the rest of the year – meaning that the absence of a large number of cardiologists, who were attending meetings, was correlated with lower mortality for these heart conditions in the hospital. In an editorial in the same issue, Dr. Rita Redberg makes a disquieting suggestion: “How should we interpret these findings? One possibility is that more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” Is there too much being done, especially by experienced physicians?

Dr. Ezekiel Emanuel, an oncologist and bioethicist, elaborated on these questions in a New York Times op-ed in 2015:

We – both physicians and patients – usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less – even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.

When specialists like neurologists or cardiologists see a patient, they approach the bedside from a unique perspective. The pathologies they know and think about are very different from what family medicine or internal medicine doctors thinks of when they see a patient. Specialists, who often act as consultants, consider the diseases they are most worried about within their field. They’ve been asked to see the patient to recommend workup for a disease potentially related to their area of expertise. Their view, in other words, is necessarily myopic – if you give a carpenter a hammer, surely the carpenter will find a nail. This does not always happen, but by nature there is a bias when a consultant approaches a patient – and that bias is toward ordering another test, toward doing something. Part of the art of medicine, especially as a specialist or consultant, is figuring out when the patient needs something and when the best approach is to do nothing at all. Our patient at the beginning of the story did not really need a repeat CT scan. To be sure, the cardiologist didn’t recommend it simply to radiate the patient or increase the hospital bill. But none of us wanted to miss something.

A conservative method of practice can come with experience, but as evident from the JAMA study referenced above, that’s not necessarily the whole story. Some of this, I think, requires thinking regularly about how well the patient in front of the doctor is doing and how a test will change the course of the patient’s treatment. “Will this change our management?” is a question our attending physicians always ask us before we order a test. And it is a question all doctors must ask themselves.

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