Thursday, May 22, 2014

Why doctors take pleasure in reporting abnormalities of no clinical importance

Modern medical practice seems to be based on ordering tests and scans , and relying on these in order to make a diagnosis - not on the old-fashioned taking a history or doing a clinical examination.

The problem with a lot of these tests is that they will pick up a lot of minor abnormalities , which are of no clinical importance . In fact, the more expensive the test ( either because it’s brand new or uses highly sensitive technology), the better the chances of the results coming back as abnormal ! While a lot of these abnormalities are often found in normal health people as well, doctors tend to get very excited when they find these.

Lots of doctors take pride in finding and highlighting these abnormalities - and there are many reasons they do so.

For one, doctors are trained to look for problems, find abnormalities and make a diagnosis. Remember that doctors do not see healthy people – they only see ill patients ! Since they are often clueless about the natural history of a  disease and the prevalence of the abnormality in the general population, they tend to overdiagnose and overtreat.

During training, they are taught to take pride in finding lesions and abnormalities which other doctors have missed. If you are trained to do something , you tend to do it and it takes time to develop the maturity to understand the harmful consequences of some of this training. with Doctors can be very competitive and love playing the game of one-upmanship ! If one doctor finds something another one has missed, it proves to them that they are better than the rest !

Also, the fact that the doctor has ordered a test means he needs to justify the expense of the test to the patient. The best way of doing this in highlighting the abnormality, thus proving to the patient how competent and efficient they are.

Thus, it is very common to find small ovarian cysts or tiny fibroids when vaginal ultrasound scans are done for infertile women. This sets up a positive virtuous cycle for the doctor, who can claim that he has finally made the right diagnosis, and is now justified in doing additional procedures to solve the problem. He can suggests additional procedures to correct the problem . Unfortunately , from the patient's point if of view, this becomes a negative vicious cycle , because a lot of these abnormalities are just incidental findings which are of no clinical importance and are best left alone. However, patients now become the worried well , and start obsessing about these little incidental findings . They allow themselves to be subjected to unnecessary interventions and procedures , which actually end up causing more harm than good - for example , laparoscopic surgery to “treat” a small cyst.

The sonographer will highlight these abnormalities by printing them in bold or in italics. When the patient reads the report, she gets understandably upset and does a google search which confuses her even more, because so much of the information available online is unreliable. When she finally sees the doctor, he triumphantly points out the abnormality and says that once I treat this, you’ll get pregnant !

The reason we are seeing an epidemic of overtesting and overtreatment today is partly because of the way doctors are economically incentivized to practice medicine .  They get paid to order tests and do procedures, and as rational humans, this is what they do.

Unfortunately , none of this is in the patient's best interest . The biggest tragedy is that the poor patient doesn't even realize that they have been subjected to unnecessary testing ! When the test is abnormal , they are happy their doctor has been clever enough to find the problem and “treat “ it. When the test result is normal, they are reassured that “ all is well” !

It’s only senior and more mature doctors who understand the importance of masterly inactivity. Unfortunately, doctors don’t get paid to do nothing – and not enough patients have the maturity to understand that only the superior doctor will advise a hands off approach.

Intelligent patients, who invest in information therapy , understand that it’s best not to worry about very little abnormal squiggle on an ECG -  and that often the best medical treatment is to do nothing.

Intelligent patients can try to protect themselves from overtreatment by getting a second opinion , but sadly this also doesn't often work very well , because the doctor who provides the second opinion is also incentivized to perform a procedure , rather than do nothing. This is why it’s best to get a second opinion from a retired surgeon , who has years of experience and expertise , and who doesn't operate anymore, because he will be able to explain to you why a hands-off approach is in your best interests.

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