Hard Cases
Dr. Abigail Zuger on the everyday ethical issues doctors face.
I spent the usual long afternoon at work doing little but ordering tests, far more than I honestly thought any patient needed, but that’s what we do these days. Guidelines mandate tests, and patients expect them; abnormal tests mean medication, and medication means more tests.
My tally for the day: five hours, 14 reasonably healthy patients, 299 separate tests of body function or blood composition, three scans and a handful of referrals to specialists for yet more tests.
Teachers complain that primary education threatens to become a process of teaching to the test. They wince as the content of standardized tests increasingly drives their lesson plans, and the results of these tests define their accomplishments.
We share their pain: Doctoring to the tests is every bit as dispiriting.
Some medical tests, like blood pressure checks, are cheap and simple. Some are pricier and more complicated, like mammograms or assays for various molecules in the blood that correlate with various diseases. We order them all at prescribed intervals, and if we happen to forget one, either by accident or design, electronic medical records nag us mercilessly until we capitulate.
As in education, our test-ordering behavior and our patients’ results increasingly define our achievements, and in the near future our remuneration is likely to follow. Still, like all test-based quality control systems, ours can be gamed. Our tests can also inflict unnecessary psychic damage, and occasional physical damage as well.
Most distressing: Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.
It is all in the name of good and equitable health care, a laudable goal. But if you reach age 50 and I cannot persuade you to undergo the colonoscopy or mammogram you really don’t want, am I a bad doctor? If you reach age 85 and I persuade you to take enough medication to normalize your blood pressure, am I a good one?
I am not the only one who wonders.
A cadre of test skeptics at Dartmouth Medical School specialize in critically examining our test-based approach to well adult care. If you are confused about mammography, colonoscopy or the PSA test for prostate cancer, these folks deserve much of the blame: They have repeatedly demonstrated that these tests and many others do not necessarily make healthy people any healthier, any more than standardized testing in grade school improves a child’s intellect.
Dr. H. Gilbert Welch, a Vermont physician who is part of the Dartmouth group, has a new book that might serve as the test skeptic’s manifesto and bible. Its title, “Less Medicine, More Health,” sums up his trenchant, point-by-point critique of test-based health care and quality control.
In medicine, “true quality is extremely hard to measure,” Dr. Welch writes. “What is easy to measure is whether doctors do things.” Only doing things like ordering tests generates data. Deciding not to do things and let well enough alone generates nothing tangible, no numbers or dollar amounts to measure or track over time.
Dr. Welch points out that doctors get to become doctors because they are good with tests, and know instinctively how to behave in a test-focused universe. Rate them by how many tests they order, and they will order in profusion, often more than the guidelines suggest.
They will do fine on assessments of their quality, but patients may not do so well. Even perfectly safe tests that are incapable of doing their own damage may, given enough weight, trigger catastrophe.
Yes, little blood pressure cuff over there in the corner, that means you. The link between very high blood pressure and disease is incontrovertible, and the drugs used to control blood pressure are among the cheapest and safest around.
Even so, as Dr. Welch pointed out in a recent conversation, systems that rate doctors by how well their patients’ blood pressure is managed are likely to invite trouble. Doctors rewarded for treating aggressively are likely to keep doing so even when the benefits begin to morph into harm.
That appears to happen in older adults, at least in those who avoid the common complications of high blood pressure and continue on medication. One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, with death rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster.
Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds. Not yet, at least. Someday, perhaps, not ordering and not prescribing will mark quality care as surely as ordering and prescribing do today.
Children go to school to learn. Adults go to the doctor … why? If they are sick, to get better, certainly. But for the average healthy, happy adult, let’s be honest: We really haven’t completely figured out why you are in the waiting room. And so we offer a luxuriant profusion of tests.