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How Can We Curb the Medical-Testing Epidemic?

The views expressed are those of the author and are not necessarily those of Scientific American.

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We are facing an epidemic in this country, a threat to our health caused not by pathogens, environmental toxins or lousy diets but by medical tests. Over the past couple of years, we’ve learned that two popular tests for cancer—mammograms and the PSA (prostate-specific antigen) test for prostate cancer—are less than useless for many people. Men are 47 times more likely to get unnecessary, harmful treatments—biopsies, surgery, radiation, chemotherapy—as a result of receiving a positive PSA test than they are to have their lives extended, according to a major European study. The ratio for women undergoing mammograms is between 6 and 33 to one, according to a new analysis by researchers at Dartmouth.

Now Gina Kolata, who has been diligently tracking debates over medical testing for The New York Times, reports on a recent study in which 31 professional baseball pitchers were scanned with magnetic resonance imaging. The study revealed that 28 of the pitchers had abnormal shoulder cartilage and 27 had abnormal rotator cuff tendons. Here’s the problem: all of the pitchers were perfectly healthy, throwing without any pain. This and other studies, Kolata asserts, show that MRI scans “are easily misinterpreted and can result in misdiagnoses leading to unnecessary or even harmful treatments.” I suspect that critical evaluations of many other medical tests would yield similar conclusions.

Several years ago, I got first-hand experience of just how test-crazy modern medicine has become. My teenage son Mac mentioned during a routine checkup that he occasionally heard a weird buzzing noise. Mac’s pediatrician couldn’t find anything wrong with him, but she told me that tinnitus, or ringing in the ears, is sometimes caused by tumors on the auditory nerve. This possibility was highly unlikely, she assured me, but just to be sure, Mac should have an MRI scan.

The radiologist who carried out the MRI said Mac’s brain looked fine, but a tiny fuzzy spot in his inner ear could indicate fraying of the insulation of the auditory. This possibility was highly unlikely, he added, but just to be sure, Mac should see a neurologist. The neurologist said the MRI spot was insignificant, and his tests of Mac came up negative. The neurologist nonetheless recommended a second MRI, followed by another consultation with him and an inner-ear specialist. Just to be sure.

Then while I was driving Mac and two friends to a movie, he started talking about his medical odyssey, and his friends said they sometimes heard weird noises in their heads too. I called back the neurologist, and he said, yes, temporary tinnitus often arises for no discernable reason in teenagers, and usually it fades away harmlessly.

Now he tells us! To Mac’s relief, since the tinnitus had never bothered him that much, we canceled the next round of appointments. The university where I teach provides my family with excellent medical insurance, so our cost was a $20 co-payment for each visit—plus of course time and anxiety. On the other hand, all those tests and consultations easily cost thousands of dollars.

Excessive medical testing helps explain why U.S. medicine costs so much and delivers so little. In 2009 the U.S. spent $7,960 per person on health care, a rate 35 percent more than the next highest-spending nation, Norway, and more than double the rate of France, Sweden and Britain, according to an analysis by Ezekiel Emanuel, a professor of health policy at the University of Pennsylvania. And yet all these countries have much healthier populations than the U.S. does.

“Almost no matter how we measure it—whether by life expectancy or by survival for specific diseases like asthma, heart disease or some cancers; by the rate of medical errors; or simply by satisfaction with health services—the United States is actually doing worse than a number of countries, like France and Germany, that spend considerably less,” Emanuel asserts. Americans rank 36th in life expectancy, tied with Cubans.

Cancer screening in particular is “vastly overused in the United States, with about 40 percent of Medicare spending on common preventive screenings regarded as medically unnecessary,” according to an investigation by the Center for Public Integrity. “Millions of Americans get such tests more frequently than medically recommended or at times when they cannot gain any proven medical benefit, extracting an enormous financial toll on the nation’s health care system.” PSA testing alone costs about $3 billion a year, according to the test’s developer, Richard Ablin, an immunologist at the University of Arizona. He calls PSA screening a “profit-driven public health disaster.”

Over-testing undoubtedly stems in part from greed. Most American physicians are paid for the quantity of their care, a model called “fee for service.” Doctors have an economic incentive to prescribe tests and treatments even when they may not be needed. Physicians also over-prescribe tests and treatments to protect themselves from malpractice suits. I blame consumers, too, for being too eager to submit to tests that have negligible value. In Kolata’s story on MRI scans, a physician tells her that patients “often feel like they are getting better care if people are ordering fancy tests, and there are some patients who come in demanding an MRI.”

So what are my prescriptions for curbing the testing epidemic? First, the fee-for-service model should be replaced with a different compensation scheme—perhaps one that gives physicians a flat salary with bonuses for improved patient outcomes. The Mayo Clinic and other hospitals that have adopted this practice deliver better care at lower cost. Second, malpractice laws should be revised so that doctors don’t prescribe tests simply to avoid lawsuits. Third, we need better evaluations of the efficacy of all medical tests. Fourth, consumers should try to educate themselves about the risks and benefits of tests. They might start by reading Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 2011), by physician H. Gilbert Welch and two colleagues at Dartmouth.

Oh, in case you were wondering, my son Mac no longer hears that funny buzzing sound.

Photo courtesy Wikimedia Commons.

John Horgan About the Author: Every week, hockey-playing science writer John Horgan takes a puckish, provocative look at breaking science. A teacher at Stevens Institute of Technology, Horgan is the author of four books, including The End of Science (Addison Wesley, 1996) and The End of War (McSweeney's, 2012). Follow on Twitter @Horganism.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. Shecky R. 1:01 pm 11/7/2011

    totally agree; waaaay too much costly routine medical testing going on; Dr. Nortin Hadler is another author (gadfly) who has written repeatedly about this.
    I will say though it’s not 100% the fault of clinicians, but also the fault of a legal system that forces doctors into a defensive (lets not miss a diagnosis) posture is also very much to blame.

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  2. 2. Elaine Schattner 1:33 pm 11/7/2011

    re: “The ratio for women undergoing mammograms is between 6 and 33 to one, according to a new analysis by researchers at Dartmouth.” The assumption-laden, “new” analysis covers decades-old data. This paper misrepresents the accuracy of modern radiology and breast cancer detection and is misleading to women.

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  3. 3. byronraum 4:39 pm 11/7/2011

    I wonder why it is that more hospitals (or hospital chains) do not offer insurance plans, and why more insurance companies don’t own their own hospitals. Surely they realize that they can make considerably more money by reducing the costs of billing between hospitals and insurance companies and also cutting down on unnecessary testing. Perhaps there are already monopolies or duopolies in the area they serve, so don’t feel a need to optimize?

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  4. 4. PhillyJimi 5:24 pm 11/7/2011

    The system is setup completely backwards. Run the test and make more money. Run the test it protects you from lawsuits. Hospitals buy big fancy test machines so they can make more money, they want Doctors to use them. Healthcare is only about making money. Insurance companies only want to insure the healthy. Doctors are caught up in the middle while the lawyers circle the waters waiting for a drop of blood. And everybody is scared about changing anything.

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  5. 5. Nagnostic 11:25 pm 11/7/2011

    Everything anybody does that isn’t associated with reclining on a beach with a cocktail is done for money.
    Doctors do what they do for money, just as an auto mechanic or insurance adjuster does what they do for money.
    Doctors have been encouraged to do tests because of the liability involved in not doing them. This relationship is well established.
    So many readers here assume that the tests are done because of “greed”. Tiresome! Maybe they would be better occupied by occupying Wall Street an parroting the party line there.

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  6. 6. Nagnostic 11:32 pm 11/7/2011

    byronraum – A group of doctors set up a medical co-op in New York state. The clients were to pay an annual fee for their medical services.
    The insurance industry got wind of it and put the bureaucrats on the case. It seems those doctors were practicing insurance without a license.
    End of story.

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  7. 7. Nagnostic 11:34 pm 11/7/2011

    The obvious solution to high medical care costs is the outlawing of medical insurance.

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  8. 8. Nagnostic 11:39 pm 11/7/2011

    Actually, the true solution is the outlawing of medical care.

    After all, doctors help keep humans alive.

    Humans weave nets in order to kill dolphins and whales.
    Humans build bird-chopping wind turbines and dams that thwart fish mobility.
    Humans cause global warming.

    Doctors should be extinguished, so humans can be allowed to die. Only then can the bluebirds and fairies flourish.

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  9. 9. gmperkins 6:20 pm 11/8/2011

    When there is a good test, you get good healthcare because it shows yes/no clearly. When a yes, doctors are very competent (typically) on how to procede.

    The problem are the iffy tests. Just as you describe with your son. If that first MRI had no fuzzy spot, it would have ended there. But it did and I bet alot of MRIs have some minor stuff lingering about. The MRI is a great tool but it is clearly being over-used and we either need to improve how MRI results are interpreted or we need to improve the MRI’s results so that they are easier to interpret.

    My own story for this is a torn ACL. The knee specialist I went to diagnosed it with a ‘thump’ test and told me with certainty that I had torn my ACL. But ‘to be sure’ he ordered an MRI. The MRI wasn’t conclusive and so was a waste of 1500$. The operation was a complete success. The doctor’s test along with my knee buckling when I twisted, was more than enough information to determine a torn ACL. I wish I had declined the MRI but at the time I was under the impresion that MRIs were really important to get (was the all new “magic machine” at the time).

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  10. 10. jgrosay 6:30 pm 11/8/2011

    The easiest way to reduce “unnecesary” medical tests of all kinds would be reducing the number of malpractice suits, and the amount of money in the compensations for medical errors. Probably the degree of health impairment from abandoning defensive medicine, and also the cost reduction from this can be estimated, but there are ethical issues in this, too. Salut +

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  11. 11. dubina 1:45 am 11/9/2011

    What are Horgan’s prescriptions for curbing the testing epidemic?

    First, the fee-for-service model should be replaced with a different compensation scheme—perhaps one that gives physicians a flat salary with bonuses for improved patient outcomes.


    Second, malpractice laws should be revised so that doctors don’t prescribe tests simply to avoid lawsuits.

    Yes, but the notion that tests are prescribed to avoid lawsuits is dubious. I would be money more tests are prescribed to make money than to avoid lawsuits. Why has that proposition not been tested?

    Third, we need better evaluations of the efficacy of all medical tests.

    Agree. And those evaluations should be availble for inspection on the Internet.

    Fourth, consumers should try to educate themselves about the risks and benefits of tests.

    Agree. And that education should be availble on the Internet. Why is it not? Who will do it? I suppose it should be composed and administered by a Federal agency, one able to datamine a Federal trove of patient ills, treatments and outcomes.

    Realy, the first step in curbing costly, unnecessary, ineffective medical testing is to assert the fact that it is publicize the fact that it is costly, often unnecessary, and often ineffective.

    Good show, Horgan.

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  12. 12. toothman51 10:02 am 11/9/2011

    Clarification: Drs. Do not get any incentive for prescribing or ordering tests. As a matter of FACT, kick-backs or referring to a lab/center which the Dr. owns is completely illegal, and the Federal agencies are constantly monitoring this, and very heavily I might add.

    The truth is, a Dr can see, in his lifetime, maybe a few thousand cases like the one described here. Because any possible consequence is so rare, and as a matter of good public health policy, he probably should just dismiss it and not burden the system and the patient with wasted time and moneys. However, if after 30 years of practicing medicine and dismissing findings like these he happens to miss one bad consequence, it could cost him everything he has worked for his entire life and the system would not give a Damn. Therefore,strong reform is necessary.

    Last: Eventhough everything I stated is true, in the examination room, at that moment when Drs. are trying to reach a correct diagnosis, MOST do not practice defensively. They order tests keeping in mind the best interest of the patient. They understand how terrible it would be for the patient and how terrible they would feel themselves if they didn’t double check and miss a window of opportunity for treatment.

    Everybody has a Dr. friend who is the best in the world, who would never hurt you and you wouldn’t change for any another in the world…….
    Like I said, everybody.

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  13. 13. jaydoc 1:17 pm 11/9/2011

    Terrific article. I have worked as an Internist and as an HMO Medical Director. The HMO required non-emergency CTs and MRIs to be prior authorized to try to prevent unnecessary or inappropriate testing. That way I could be the bad guy for the doctor who really didn’t want the test done in the first place but was under a lot of patient pressure to do something. Many American patients want the testing done immediately, even if the problem is chronic or unlikely to be life threatening (I hurt my back. I need an MRI). And many a doctor has had to undergo a malpractice suit when a zebra was among the herd of horses. That is a terrible thing for anyone to undergo, whether the suit is won or lost. We are a lawsuit happy country. For example, John Edwards made a fortune and became a major political figure by successfully suing OB doctors whose patients had birth defects – even though about 3% of babies have been born with birth defects throughout history. So the problem is not an easy one to solve. Patients who are harmed by inappropriate care deserve compensation, but what is inappropriate care is often a gray area.

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  14. 14. DPWalker 3:55 pm 11/9/2011

    I’m patient A and I have had a handsome chunk taken from my paycheck monthly for health insurance. I only pay a $20 co-pay to visit a physician. If a malady is suspected, I want all the necessary testing and imaging done in my case. After all, I’ve paid into the system all these years and now is the time to reap the benefits of modern medicine and its high-tech “miracles” in my case. Forget the free market and “shopping around” for the most economic care; I want the best I can get.

    “Toothman’s” point is excellent. I don’t think the general public has any feel of the threat posed to an individual practioner when the “Legal Lottery Man” comes knocking on his door. A lifetime of study, work, and equity accumulation is often at stake. Defensive medicine is the result.

    Medicare sets the fee schedule and private insurance companies follow suit. This system has fragmented the medical community into factions of specialists battling each other for their “piece of the pie” and undermining organized medicine’s unified front for influencing the government and public concerning medical issues which might truly benefit them. This “jockying” at the payment trough has produced, for instance, a $7,000 radical prostatectomy vs. a $40,000 course of radiation for prostate cancer. No wonder many urologists are placing X-ray treatment equipment in their group offices and are sending their patients for radiation instead of surgery! This is only one example of how skewed the system has become. But what do I care…it’s only a $20 co-pay to me. (Although I have noted that my premium is going up again.)

    Gone is the friendly family doctor who makes a house call, takes your temperature, holds your hand, and tells you to “take two aspirin and call me in the morning.” He’s been replaced by some truly miraculous technology which has improved quality and quantity of life. However, this has come at a cost. Technology is not cheap and is improving all the time. An average individual cannot afford care when a truly serious medical event occurs in his life. Insurance is needed for that episode. However, more rationality needs to come into play for routine care. Hope remains for a way out of the current medical mess but it will probably be long and complicated.

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  15. 15. toothman51 10:23 pm 11/9/2011

    Thanks. And I must re-emphasize.

    Drs. Do not get any incentive for prescribing or ordering tests. As a matter of FACT, kick-backs or referrals to a lab, X-ray center, or any other ancillary medical service in which the Dr. may have any kind of vested interest is completely illegal. The Federal and State regulatory agencies (FDA, DEA, etc.) are constantly monitoring this and are very efficient at it. Not even to a lab owned by a family member or by anyone who may have a close relation with the referring physician and give the appearance that there may be a conflict of interest..

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  16. 16. jysting 2:07 am 05/11/2012

    A long recognized accelerant in burgeoning health care cost is the performance of unnecessary diagnostic tests and the use of the newest or most expensive yet unproven medical therapies and technologies, in a mistaken assumption that such costly measures bolster medicolegal defence against malpractice claims 1, 2 additional to the protection afforded by sound medical judgment and the application of evidence based patient-centered care. Defensive medicine remains a substantial driver of health care cost inflation today.3 Although the inclusion of cost conscious care in medical education is likely be effective at restraining health care expenditure yet still deliver excellent individual patient care, 4 attitudinal hindrances remain. Aside from concerns about higher malpractice exposure risk, 1-3 cost containment is still strongly felt to be within the purview of administrators 5 as well as being a threat to clinician autonomy when imposed by an external authority. 2 I would also recommend that increased impetus for clinician cost consciousness be complemented by educating high schoolers about individual and societal equity in the context limited health care resources.
    Angell M. Cost containment and the physician. JAMA 1985; 254: 1203-7.
    Leitman R, Taylor H, Edwards JN. Physicians’ responses to their changing environment. J Am Health Policy 1992; 2: 35-9.
    Hermer LD, Brody H. Defensive Medicine, Cost Containment, and Reform. J Gen Intern Med 2010 Feb 9. [Epub ahead of print]
    Cooke M. Cost consciousness in patient care-What is medical education’s responsibility? N Engl J Med 2010; 362: 1253-5.
    5. Wilf-Miron R, Uziel L, Aviram A, Carmeli A, Shani M, Shemer J. Adoption of cost consciousness: attitudes, practices, and knowledge among Israeli physicians. Int J Technol Assess Health Care 2008; 24: 45-51.

    When a patient insists on a treatment or test that confers minimal benefit, a time pressured physician will be sorely be tempted to keep the peace (and the patient) by conceding.

    …and of course pathology and radiology services not to mention Big Pharma are aggressive in promting unnecessary tests and drugs….

    Wide dissemination of knowledge regarding the increased health risk of associated with HRT use not only threatens profitable sales but also attracts potential costly litigation. Wyeth’s deployment of academically respectable opinion (“Ghost Stories,” The Weekend Australian Magazine Apr 3-4) to counter bad press regarding HRT is not an unexpected response to counter these threats. Arresting HRT’s embattled clinical reputation requires the repudiation of emerging evidence that HRT is less beneficial than once believed and even poses harm. Wyeth’s countermanding strategy adds weight to empiric evidence of pharmaceutical company funded clinical trials and publications being more prone to exaggerated or selective reporting of health benefits compared with non-sponsored studies. An additional concern is the deliberate underemphasis of known adverse effects of widely used drugs such as HRT.
    Wyeth’s influence on the intellectual content of Dr Eden’s published work would be less difficult to discern if a declaration of actual or potential conflict of interest, such as that exists for authors sponsored or funded by drug companies, is explicitly included in the articles. This and the stated provenance of an article (whether commissioned by a drug company, whether independently reviewed for scientific credibility) would incite in the reader due caution in interpreting potentially misleading claims about the benefit of harm of a drug.

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