Elsa Pearson, MPH, is a senior policy analyst at Boston University School of Public Health. She tweets at @epearsonbusph.
The US health system pushes treatment over prevention. This approach has many flaws, one of the most unfortunate and costly being overdiagnosis and overtreatment.
Overdiagnosis is defined as the “detection of psuedodisease,” or disease that will never cause the patient any issues. Overtreatment is treatment that provides no benefit and may even harm the patient. One survey found that physicians consider more than 20 percent of all care unnecessary, including one in every four tests.
This phenomenon is driven by several factors, including health system consolidation and provider and patient perception. Kendra Allan, a physician assistant, emphasizes the pressure she feels to “do something” when patients come to her with new concerns. As a result, providers fall into the habit of overprescribing and patients come to expect it.
Education is one of the biggest weapons we have against unnecessary care. Providers need to know when to forgo tests and treatments and patients need to know when to say no.
But it’s not that easy in reality. Even the experts fall victim. Here are a few stories. I’ll go first.
Elsa, senior health policy analyst
I have celiac disease, an autoimmune disease, which will make me prone to osteoporosis when I’m older. In my early twenties, my primary care provider ordered a bone density scan to look for osteopenia, the precursor to osteoporosis. With no prior indication of poor bone health, I asked her why. She said we needed a baseline scan before I entered menopause. I declined the scan until the results would have an impact on my treatment plan. We agreed to talk again in twenty years.
Alex, health science specialist
I began to experience double vision. I went to my primary care provider, the emergency department, an optometrist, two ophthalmologists, and two neuro-ophthalmologists. I underwent two MRIs, a CT scan, three eye exams/dilations, rounds of blood work, and finally surgery. The double vision still isn’t resolved. What’s worse, an incidental finding of a benign pituitary tumor turned into more visits with primary care, neurology, and endocrinology, with all the associated testing. I am now triaging which of my appointments are actually important and which I can ignore.
Austin, health economist
About eight years ago, I had a kidney stone, diagnosed with a CT scan. After the CT scan, my urologist suggested I needed an x-ray, too. “Doesn’t a CT scan provide more information than an x-ray?” I asked. He said yes. I asked if my treatment would change at all based on an x-ray’s findings. He said no. I then asked what the x-ray was really for and he couldn’t answer. I declined the extra imaging study and switched doctors.
Aaron, physician and researcher
When I was in medical school, I experienced a bout of extreme abdominal pain and was admitted to the hospital. My care team ordered a swath of tests, most of them unrelated to my original complaint, including multiple CT scans, an echocardiogram, and blood and urine tests, which even led to a cystoscopy. I had a significant reaction to the dye used for one of the CT scans, and I was prescribed antibiotics even though there was no indication I needed them. Ultimately, I left the hospital with diagnoses for heart- and kidney-related issues that had never impacted my health before and likely never will, and for which treatment is unnecessary. I was never told what caused my stomach pain.
While disappointing, it’s oddly comforting that even experts are victims of overdiagnosis and overtreatment. But there are ways you can advocate for yourself next time you’re at the doctor’s office.
Ask questions. Many tests and treatments are complicated. If something is confusing or feels different from your typical treatment plan, ask your provider about it, encourages Kendra Allan, the physician assistant. He or she should be able to explain to you the treatment recommendations and why, as well as any alternatives.
Think it over. Some tests or treatments don’t have to happen right away. If it’s not an emergency, go home and talk it over with someone. Out of the commotion of the clinic, you can weigh the pros and cons and make a measured decision on how to proceed.
Ask for a second opinion. No one provider knows it all. Aaron Carroll, who shared his story above, says you should feel comfortable asking your provider for time to seek a second opinion. This will give you a better idea of what may actually be wrong and what an appropriate treatment plan would look like.
Say no. Some tests and treatments simply aren’t necessary. If something seems excessive or if a suitable alternative exists, feel confident to speak up. Guidelines and recommendations are just that; they may not apply to your situation and there may be a clinically appropriate reason to forgo, modify, or delay care. Allan reasons that if the test won’t change your treatment plan, it shouldn’t happen. Carroll argues providers should be minimalists. “Watchful waiting” is often the most appropriate approach. You should suggest this if your provider can’t justify the proposed work-up.
In American health care, we’ve gotten accustomed to the idea that more is more. But this doesn’t translate to better health outcomes for patients. Reducing overdiagnosis and overtreatment will require a multipronged approach, from provider and patient education to insurance reform. For starters, let’s do what we can as patients and advocate for ourselves.
Research for this piece was supported by the Laura and John Arnold Foundation.
