We all know that practicing defensive medicine is commonplace. “Overtesting” — doing unnecessary lab work and other diagnostic studies (some invasive) — is justified as a way to stay out of the court room. In some cases, physicians are simply bending to “what the patient wants done.” To counteract test and procedure overuse, physicians are increasingly being told to stick to the guidelines, which generally recommend a less aggressive approach to both diagnosis and treatment.
“The push is backed by the American Board of Internal Medicine Foundation, which has asked 70 professional societies in various medical specialties to identify areas of clinical waste, from overuse of MRIs for lower back pain to imaging scans for uncomplicated headaches” (The Wall Street Journal, September 23, 2014). Even AARP is getting into the act, warning their members that “common medical tests routinely taken by Americans do more harm than good, waste billions of dollars, and could endanger your health or even your life…” (AARP Bulletin, March 2014). Yearly physicals, PSA screening for prostate cancer, annual Pap tests for cervical cancer, EKGs and exercise stress tests in asymptomatic individuals, colonoscopies after age 75, follow-up ultrasounds for small ovarian cysts: Patients and doctors are told to skip them because there’s little evidence to show any benefits.
Questionable practices are also being scrutinized more closely when it comes to treatment (Journal of the American College of Cardiology, August 4, 2014). After reviewing electronic medical records of 400,000 patients at Kaiser Permanente, researchers concluded that patients on blood pressure medications were at greater risk of death or kidney failure when treated in an overly aggressive manner, thus lowering the blood pressure too much. The study also showed that rigid, “tight control” of diabetics is also problematic, especially in older and sicker patients who are more likely to experience severe hypoglycemic episodes.
There’s no doubt that a movement toward a more “standardized,” somewhat less aggressive approach to diagnosis and treatment is underway. The bottom line is that doctors need to become familiar with the guidelines and current recommendations within their specialty and make the appropriate changes to their practice style. After all, this is rapidly becoming the new “standard of care.”