By Heather Millar
I’ve been working on a book proposal for the last couple weeks and thinking a lot about the cost of medical care in this country. Inevitably, thinking about healthcare costs brings me back to thoughts of tests: tests and tests and more tests.
There’s been quite a kerfuffle this week about a release from the American Board of Internal Medicine Foundation that suggests that 45 common procedures, most of them tests, may often be ordered unnecessarily. ABIM asked nine specialty societies—everything from cardiology to clinical oncology to radiology—to each list five procedures or tests commonly done even if not needed.
These lists are part of a multi-year ABIM effort, “Choosing Wisely,” that seeks to spark a doctor-patient dialog about these interventions. Eight more specialty boards are working to come up with similar lists. Each item listed comes with a handful of academic citations, links to scientific studies that support the recommendation.
A lot of sacred cows turn up here: CT scans for non-specific low back pain, antibiotics for chronic sinusitis, annual stress cardiac imaging for patients with no symptoms, annual colonoscopies for average-risk patients with no symptoms. You can download the lists in full here.
I bet all of us have had one or more of these treatments.
For oncology they include:
• PET, CT, and bone scans for early stage prostate and breast cancers with low risk of metastasis.
• Drugs to stimulate the growth of white blood cells, which are often knocked down by chemo, in patients with low risk of this complication.
• Tests for “biomarkers” in breast cancer survivors with no symptoms.
Some critics of the lists charge that they smack of healthcare rationing, but ABIM counters that it’s not rationing if the treatments are not necessary.
Much of the media coverage, including this article in The New York Times make the point that these lists have the potential to profoundly change medical practice.
Heaven knows we need that: Nearly one-third of American healthcare spending goes for unnecessary procedures, according to some estimates. That’s hundreds of billions that might be used for something else we need: for business growth, education, roads and bridges, or even our retirement savings accounts.
I want to believe that these lists will make a difference. Whatever your politics, I think most of us realize that that healthcare spending is a big, $2 trillion-dollar problem. Where we differ is in what we think should be done to solve that problem.
I don’t mean to get into a debate about healthcare reform here; this is not the place. But I do think that we, as patients, might do quite a lot to bring down costs if we take a hard look at ourselves, at our diseases, and our options. If doctors often order unnecessary tests, we patients often demand them.
When I was first diagnosed with breast cancer, I became a whirling dervish of testing: In just a few weeks, I had two diagnostic MRIs, an MRI-guided biopsy, an ultrasound-guided biopsy, CT scans, and new mammograms. I had genetic testing. I signed up for a clinical trial so that I could get a high-tech and fantastically expensive (about $50,000), full body PET scan to make sure the cancer hadn’t spread to my bones.
I was scared; I wanted the doctors to do everything, to spare no cost! Ferret out that cancer, whatever it takes!
At the time, I thought I was being a proactive, model patient. Now, I’m not so sure.
Looking back, I have to admit that I may have gone overboard. While I’m adopted, I don’t have the ethnic background that makes me high-risk for the BRCA1 and BRCA2 mutations that can cause breast cancer; those first genetic tests were probably several thousand dollars wasted. My cancer was Stage 1; that PET scan probably was not warranted either. Put me down for at least $60,000 of those hundreds of billions wasted.
I can’t wave a magic wand and fix our healthcare system. But I can change myself.
Next time I’m faced with a choice, with a recommended test or procedure, I’m going to ask why I’m having it. As the ABIM campaign suggests, I’m going to try to choose wisely. What does the doctor hope to learn from the test? What is my real risk of the problem the test is designed to find? What are the pluses and minuses of the procedure? Does the science show that I really, really need it?
The Choosing Wisely lists are a start, but I don’t think real change will come until we patients have more conversations like these with our doctors. We need to take the five or ten minutes to talk about what we’re doing. What do you think?