More Medical Care Is Not Always Better
Avoiding essential medical care is generally a bad idea and is meant for people who are either lazy, scared, or trying to save money. But too much health care comes with its own risks. It may be prudent to avoid certain tests or treatments and choose an alternative opinion over more visits, and a good provider can help you make that decision thoughtfully.
We are not saying that you should ever give up the help you need . When we pointed out that traveling by ambulance can be very expensive , some readers have concluded that it is best not to seek help in an emergency. This, of course, is not true: it is better to be alive and pay hospital bills than without debt, but dead. But in many non-emergencies, you – and your doctor – have the opportunity to rethink how much help you really need.
A good place to start is the American Board of Internal Medicine ‘s Choice Wise website. The Council Foundation asked medical associations to name five key things in each area that patients and health care providers should reconsider. They’ve revamped those guidelines into patient newsletters , but you can also hunt down the ones that are for doctors if you don’t mind if you switch to some medical jargon. Let’s take a look at some helpful posts.
Tests have risks and benefits
You can think of a medical test as a simple question. The questions don’t seem harmful, which is why we (and the doctors!) Often like the idea of doing a test and figuring out what’s wrong. But no test is perfect, and there are consequences for failing to do so.
Take mammography, for example. In the US, there are four different sets of guidelines for when you should start getting them, whether to ever stop, and how often you should follow them. Each one represents a slightly different judgment on how to balance the risks and benefits of this possibly overblown dough.
Take a look at this graph showing mammogram results for 1,000 women with low to moderate cancer risk. For every two cancers detected by the test, one is missed, and another 98 women are sent for further testing. This means extra days or weeks of worrying about whether you have cancer. Some of these women may need surgery, radiation therapy, or chemotherapy for cancer they don’t actually have. Some women with a low cancer risk are more likely to get hurt than mammograms help . This does not mean that the test is useless, but it is a sentence for both you and your doctor.
Here are a few more tests that, according to the recommendations of Choosing Wise, deserve doubts. Your doctor should stick to the most recent guidelines, but sometimes old habits can be difficult to break.
- Annual Pap tests for cervical cancer . Previously, they were recommended annually, but cervical cancer develops so slowly and the immune system copes with it so often that annual tests are unnecessary. Most women should have a check-up every 3-5 years .
- Blood tests for vitamin D. They are only useful for people with certain medical conditions or risk factors. Vitamin D tests usually don’t help healthy people .
- PSA tests for screening for prostate cancer . Blood tests can look for prostate-specific antigen (PSA), but there are far more false positives than useful results .
- Full body scan for cancer. They are associated with a lot of radiation and often reveal things that would not be a problem. These chance finds will then require more observations over the years, which means more scans. Only sometimes the benefits outweigh the risks .
- Blood tests for the risk of miscarriage . They are usually useless and can lead to unnecessary treatment.
- Daily blood tests if you are in the hospital. They are often ordered in the usual order, but one may ask if they are really needed. Sometimes this is not the case .
- Computed tomography of the emergency department for minor head injuries . Computed tomography cannot detect the presence of a concussion, but it may be a good idea for a serious injury that may cause bleeding in the brain. CT scans are not only useless , but also expensive and expose you (or your child) to radiation.
Many other tests, including cholesterol tests, osteoporosis tests, and colon cancer tests, make sense for people of a certain age or with certain risk factors, but they are not for everyone. See a summary of useful tests and their age ranges in this test newsletter .
Treatment also comes with risks and costs
Treatment also deserves careful scrutiny. Take antibiotics, for example. Once considered a low-risk treatment, we now recognize that side effects include killing off beneficial bacteria, which can lead to yeast infections and sometimes severe diarrhea. Too much antibiotic use also contributes to the development of antibiotic-resistant microbes such as supergonorrhea and MRSA .
Unsurprisingly, many guides for choosing the wise are about ways to avoid taking antibiotics. But there are other treatments that are worth questioning. Remember that every treatment has a cost, so even those that are harmless can be a waste of time and money.
- Cancer treatment for someone near the end of their life . Stopping treatment is a tough decision, but the likelihood that treatment could lengthen a person’s life slightly may not outweigh the fact that many of those extra days will be spent in chemotherapy hell. This discussion is worth it . And even for patients with a good prognosis, sometimes the “less is more” approach (for example, with some types of radiation therapy ) gives better results.
- Plantar fasciitis surgery. Non-surgical approaches often work best , and surgery carries the risk of permanent damage.
- Sleep studies for insomnia (but not sleep apnea) . Insomnia can usually be diagnosed and treated without it. Sleep studies do help diagnose sleep apnea.
- Physical therapy that is too light, which is often given to older people for fear that they might hurt themselves. But if the exercises are not difficult, they will not help .
- Urinary catheters increase the risk of a urinary tract infection, so they should only be used when needed .
- Replacing mercury-containing fillings with mercury-free versions may seem like a good idea, but in reality, replacing mercury releases more than remains. In most cases, it is best to leave them alone .
Sometimes one of these treatments or procedures might be a good idea for your particular situation, but it’s worth asking your doctor why she’s ordering it and if other options might be better.
What questions to ask
For tests, it is important to ask what decision will be made based on the result. Just because the test is routine, or because you or your doctor is interested in the result, does not mean that the test is helpful. For example, prenatal tests exist that can tell you if your fetus has a genetic abnormality . Since you can get a false positive or false negative result, it’s worth asking yourself: Would you do something differently (such as terminating a pregnancy) based on these results? If not, then you can say that you do not want to take the test at all.
All healthcare providers are familiar with the idea of informed consent – when you, the patient, have the right to know about the risks and benefits of a test or treatment before you agree to it. No doctor will find you strange if you ask:
- What are the risks of this test or treatment?
- What are the benefits?
- How likely is this treatment to work (or how likely is this test to give the correct result)?
- What else could we try instead?
You won’t be an overbearing patient if you ask these questions, and you shouldn’t feel bad about asking them. And don’t forget to ask, even if you are offering a test or treatment . For example, if you see an ad for a really awesome sounding drug and ask your doctor about it, don’t just say, “Hey doctor, can I have this?” but also ask about its risks and alternatives. Same idea if there is a test that you hear everyone should pass.
“There is ample evidence that a significant percentage of routine care is provided to patients who would rather avoid it if they could better understand their choices and the trade-offs that come with it,” the three experts write on the Health Affairs blog. Exploring these options and trade-offs will help you become a smarter and possibly healthier patient.
Illustration by Sam Woolley.