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Thursday, February 28, 2013

More information does not equal better care

A very insightful editorial appeared recently in the Archives of Internal Medicine.The article gave several examples of overdiagnosis in medicine, but I thought the authors did a particularly good job explaining the false hope of CT scanning to detect pulmonary emboli. Emboli occur most often when a blood clot in the veins of the legs breaks off, travels through the right side of the heart, and gets stuck in the arteries of the lungs. Symptoms for this condition include chest pain, trouble breathing, and coughing up blood.

The gist of their point was that by one measure the case fatality rate for pulmonary emboli (PE) is dropping, which technophilic physicians and others attribute to detecting more of these early through aggressive CT ordering, most commonly in the ER (and even more to their credit, the authors are ER docs). However, the conflicting national measurement is that the total number of yearly PE deaths has not changed. I think death statistics should commonly be taken with a grain of salt, but in this case I agree with the authors. The CTs are finding more PEs, but the PEs are not really life threatening.

Back in my early days of working in ERs, we would commonly send patients home with sharp sudden-onset chest pain who clearly had not had a heart attack or other similarly serious disease. This was before the faster CTs were invented that could detect PEs or a blood test called a d-dimer. It never felt that we had any epidemic of missed PEs coming back to the ER in worse shape after we sent them home the first time. I always suspected that a few of these cases were small PEs. What probably happened with the discharged patients is that the PEs dissolved on their own, damaged the lungs so little they were clinically irrelevant, and the patient went on with his life after a few days of decreasing chest pain.

I have found that this concept is hard for non-healthcare people to really grasp – that a less aggressive testing approach knowingly misses disease, but makes no difference in the overall prospects of the patient. It is crucial that the U.S. culture fights the prevailing scare tactics of the diagnostics industry, or we’ll never lower the rate of overtesting. Any administrative tricks to lower testing rates will be subverted by both physicians and patients who assume more tests equal better care unless the underlying culture and conventional beliefs are changed.

The change required is deeper than administrative rules. It has to come from a more humble attitude on the part of doctors, patients, employers, and insurers that just because a patient could be labeled as having a disease, there is nothing to be gained by doing anything about it. More information does not equal better care.
Our American culture proclaims, “Just Do It.” To reclaim resources from the healthcare industry and return them to the general economy, we must proclaim, “Don’t just do something for the sake of doing something, stand there.”

Richard Young is a physician who blogs at American Health Scare.

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