TOPICS > Health

Medical Groups Call on Doctors to ‘Choose Wisely,’ Perform Fewer Tests

April 4, 2012 at 12:00 AM EDT
Nine medical specialty groups on Wednesday released a list of 45 medical tests and procedures they say are often unnecessary and costly -- and sometimes dangerous. Gwen Ifill discusses the "Choose Wisely" campaign with Dr. Glen Stream of the American Academy of Family Physicians and Dr. Eric Topol of Scripps Health.

GWEN IFILL: Next, a call and a plan to reduce the number of routine medical tests and procedures.

Nine medical specialty groups say many of these tests are unnecessary, costly and even risky. Among the group’s recommendations, avoid using X-rays for lower back pain in routine cases. Limit stress tests or EKGs in annual physicals. Cut back on prescribing antibiotics for minor sinus infections. And scale back on treatments even for some cancer patients.

According to some estimates, nearly one-third of the money spent on U.S. health care is devoted to these types of tests, procedures and visits. You can find the rest of the list on our website.

For more on the group’s recommendations, we turn to Dr. Glen Stream, president of the American Academy of Family Physicians, and Dr. Eric Topol, a cardiologist and chief academic officer of the Scripps Health system.

Welcome to you both.

Dr. Stream, how widespread would you say are the incidents of this over-testing, overuse?

DR. GLEN STREAM, president, American Academy of Family Physicians: Well, as you described, estimates are somewhere in the 30 percent up to a full third of the costs of delivering health care to the people in our country are expended on health care testing and treatment that doesn’t contribute to their health and well-being.

GWEN IFILL: But don’t people expect to get the best tests possible to get to the bottom of their complaints?

DR. GLEN STREAM: Yes, they expect to get the best tests, and they should.

But, sometimes, the issue is that more testing and more treatment isn’t in their best interests, doesn’t add to their health, and many times actually can adversely affect their health and cause even serious complications.

GWEN IFILL: Dr. Topol, in your practice, how often would you say that people — that you get pressure from patients to prescribe things you wouldn’t recommend, and how often is it that doctors are overprescribing?

DR. ERIC TOPOL, Scripps Health: I think it’s very much tipped to the doctors overprescribing issue, Gwen.

I don’t think it’s too often that patients are demanding or strongly requesting scans and procedures. It’s usually the other way around.

GWEN IFILL: So, what drives then that, then? Why would doctors overprescribe? Is it because — I don’t know. Why would it be?

DR. ERIC TOPOL: Well, part of this is knee-jerk.

You know, there’s — we live in this kind of technocentric world in the medical community, and so it’s entrenchment in this. And part of this is this is what makes the reimbursement model, unfortunately, in the United States work. And hospitals and the medical system, this is what drives it.

GWEN IFILL: Well, let me ask you and then I want to ask Dr. Stream this, too. How does a patient know who trusts his or her doctor, how do you know what the best test is? How do you know when someone is saying, go get an EKG, it seems like a good idea, when they really don’t need to?


Well, I think that the issue there is that we need to individualize things. So, you know, to have these blanket guidelines across these various professional societies, to try to cut costs and unnecessary things, is fine. But each individual needs to be carefully assessed, and that should be a shared decision between the physician and the patient.

So, you know, you don’t want to see things standardized, because that’s, in fact, what has been largely the problem. Every individual deserves special consideration.

GWEN IFILL: Dr. Stream, I — you’re my doctor, I trust you implicitly and you tell know do something. Am I to say to you — am I — according to your guidelines, am I expected to be, as a patient, empowered to say to you no?

DR. GLEN STREAM: I believe you should be empowered.

And I see this effort today and I applaud the American Board of Internal Medicine Foundation for bringing this group together. It’s a shared educational effort to both physicians and patients to have that information, to have good shared decision-making, because you should be able to say, if I recommend a particular test or a treatment, is that the right thing for you, and what’s the chance that that is going to help you and what’s the chance that that might harm you?

And I think perhaps the experience is different in different specialties. I, as a family physician, I often see patients who ask for specific treatments. Antibiotics for a sinus infection is one of the examples for my academy, or, you know, I have had terrible back pain for a week, don’t I need a X-ray?

And it can be difficult to explain to patients that an X-ray, if they don’t have certain warning signs, is not likely to contribute to their treatment, but could involve not just unnecessary expense, but unnecessary X-ray exposure.

GWEN IFILL: What about potentially life-threatening diseases like cancer? Don’t you want to take as many tests as possible to rule out the possibility or to catch a cancer early, which is what we have all been told has to happen?

DR. GLEN STREAM: Even in those serious illnesses and in the cardiology realm — and I will certainly defer to Dr. Topol as well — but there’s certainly such a thing as too much testing.

The American College of Cardiology in their five items for this effort identified those things. So even for someone with established heart disease, what’s the interval of time at which they should have certain follow-up tests? Because overtesting and overtreatment can truly be harmful.

GWEN IFILL: Dr. Topol, this is not the first time that the medical academy has tried to scale back on testing. Wherever there was a report that comes out about slowing down the number of mammograms, for instance, there’s always an outcry. Why would this be different?

DR. ERIC TOPOL: Well, you know, this is a long-overdue issue.

And this is not an emotional thing. This is overuse of testing. Go back for a second to something that Dr. Stream was commenting on. In cardiology, all too often, every year, we have nuclear stress tests ordered as a routine, knee-jerk thing. And that exposes each individual to a lot of radiation, equivalent to thousands of chest X-rays.

And this is just crazy that it’s continuing. And it’s about time that we saw professional societies like cardiology and these others start to make a statement that this is not the acceptable norm. It might be right for individual patients, but it shouldn’t be for all patients in each of these disciplines.

GWEN IFILL: But I guess my question, Dr. Stream, is, why is it that doctors would pay any more attention to these recommendations than they have to recommendations like this in the past?

DR. GLEN STREAM: Well, I think that the advantage is this concerted effort not just in one specialty, but these specialties working together. I believe that we have better information available from medical studies just over the last several years that highlight the issue of overtreatment, and it’s not intended specifically as a cost-saving effort.

It’s really is truly to use the best care when necessary and avoid treatment and testing that’s not helpful. But the consequence will be to save a significant amount of health resources that then can be directed to those people that need those services.

GWEN IFILL: Dr. Topol, what about doctors who worry that if they don’t take every — make every available test, that they will be more vulnerable to malpractice claims?

DR. ERIC TOPOL: Well, that’s a concern, Gwen.

It’s unfortunately a legitimate one. And that’s one of the excuses that is all too commonly used for this overtesting problem, really what could be considered a longstanding epidemic. But I don’t think in most cases, unless there’s clear-cut justification, that that would come into play.

I think it’s too often used as an excuse to cover things. But just — normally, it’s just you have this particular condition, I’m going to do these tests or order these procedures or prescriptions, and there’s just not enough of this one-to-one matching of what the patient’s real needs are with what ought to be done.

GWEN IFILL: Is this one of the conversations that came up in your recommendations and your thinking this through in your group, Dr. Stream, that perhaps doctors might resist?

DR. GLEN STREAM: It really wasn’t brought up that much in our group, but — and I think that the reason is that the idea of using this information to enable that shared decision-making will enable the patient to feel inputted and some control over what testing and treatment they have, as opposed to a “Whatever you think, Doc” sort of an approach, where then there is second-guessing after the fact.

I think if patients are given good information, here’s your condition, here’s an option as far as testing or treatment, here’s the benefits and the risks, and you together choose the right treatment.

GWEN IFILL: How do you weigh the benefits and the risks?

DR. GLEN STREAM: Well, I think it’s difficult, even for physicians and — when we are patients. And we all are patients at some point in our life. If it’s an area outside of your specialty, it’s hard to be fully informed.

And yet I think it’s a responsibility of physicians to do the best they possibly can to explain that risk and benefit to patients about various tests and treatments that are being recommended.

GWEN IFILL: Dr. Topol, is this something which can take hold immediately, or is this something that is going to take a whole change in the way we approach our doctor-patient relationships and our treatment relationships?

DR. ERIC TOPOL: I wish it would take place quickly, Gwen.

But the reality is that the medical community moves incredibly slow. It’s ultra-conservative, resistant to change. So these things are long overdue. They’re in the best interest of patients and certainly for the — addressing the health care crisis economic issue.

So the problem is, there’s no enforceability, and so it’s unlikely that this will make a substantive change in the short term.

GWEN IFILL: At least not in the short term.

Dr. Eric Topol, Dr. Glen Stream, thank you both very much.

DR. GLEN STREAM: Thank you.