When it comes to health care, we need to think about this phrase: "Just because we can, doesn't necessarily mean we should."
Not many years ago, physicians had a limited array of testing available to make a diagnosis. In the past couple of decades, however, the number, variety and complexity of testing has expanded exponentially.
Beyond X-rays, we now have computer-generated CT scans, MR scans and PET scans. We now have a vast array of interventional techniques for imaging, including angiography, ultrasonography and others. We have far advanced chemistry testing and genetic testing that can identify inborn errors of metabolism, occult tumors and other ongoing or potential disease processes. And we have developed whole diagnostic testing laboratories, where we can obtain tissue samples via percutaneous routes that in the past would have required major surgery.
With each advance in testing, a new protocol for defining when and how to use these tests arises and becomes a "standard of care." Last year, there was a major conflict when the Institute of Medicine came out with a much less vigorous set of guidelines for doing mammography testing.
Why the less vigorous guidelines? First of all, mammograms were resulting in many false positives that resulted in the need for more testing and caused significant anxiety among the women who were faced with these additional tests. Secondly, there was strong evidence that the age and frequency guidelines were not significantly detecting more cancers or doing it sooner to save lives.
There was an immediate outcry from many that we should not change the guidelines. Many women testified that they were alive because they were tested under the older guidelines.
In males, the prostate-specific antigen, or PSA, is a test that has become nearly standard to rule out prostate cancer. PSA will gradually rise in virtually all men as they move from the 60s into the 70s and 80s. As a consequence, the test will continue to rise in "normals." A sudden increase may be significant, but there is no absolute number at which treatment should be undertaken. When the PSA rises, the protocol suggests the need for a prostate biopsy, yet many of those are proving to be negative for cancer because of a false positive in the form of a rising PSA. For everyone who questions the benefit of doing an annual PSA, there is someone who claims that the testing saved their life.
In the 1930s, Vermont farmer Wayne Newton was the first person to be operated on for a diagnosis of a herniated disc in his lower back. The surgeon involved later said the worst thing that happened was that Wayne got better. Ever since, we have collectively had a fixation on repairing herniated discs. Most back pain, he said, has nothing to do with disc herniations.
Almost weekly, I see a new patient in the office with a complaint of back pain. Most have already had an X-ray and an MRI of the spine. When I ask them what is wrong, the common answer is, "I have a herniated disc." Technically, when we look at the MRI, they do have a herniated disc, but it probably has little or nothing to do with their pain. I point out that the symptoms from a disc herniation are those of leg pain and not back pain.
As a medical student, a neurologist introduced us to the "Matterhorn syndrome." He said if we do five tests on a patient and one comes back slightly abnormal, we then do four more. If one of those is abnormal, we then do even more. Eventually, we have created a mountain of data that may or may not have anything to do with the patient's problems.
We may have a vast arsenal of testing capability, but every time we do a test, we run the risk of getting a false positive. Acting on that by doing more testing or by treating a problem that is asymptomatic may have no impact on the health and well being of the patient. Yes, there are times when testing is necessary and helpful and will save lives and improve health. But "just because we can, doesn't mean we should."
To control the cost of health care, we need to question the amount of screening exams. Maybe a better history and physical examination could avoid the need for multiple tests. It's possible that further intervention may be futile and cause more harm than good for the patient or the family.
David G. Welch, M.D. lives in Lake Placid.