Do Doctors Know Best?
A rebuttal to http://www.ratemds.com/social/?q=node/56128 sort of....
We haven’t had a medical article posted for awhile.
The Trouble With ‘Doctor Knows Best’
Doctors were told last month that we should stop doing so many screenings for prostate cancer with the prostate-specific antigen test. We learned that sigmoidoscopy is a cheaper, easier and effective alternative to colonoscopy for colon cancer screening. And a study I led turned up strong evidence that routine lung cancer screenings are justified only for people at high risk because of heavy smoking in the past.
Regular mammograms aren’t necessary for women in their 40s and are needed only every two years for women ages 50 to 74, the United States Preventive Services Task Force has decided. For many women, Pap smears are required only every three years, not every year, the group also says now.
This deluge of do-less recommendations results from research into tests and procedures that have been arguably overused. You’d think these pronouncements would bring a sea change in the way patients are treated in this country. But my guess is that little will change. Many doctors, maybe most, will ignore these findings and keep doing what they have been doing all along.
The PSA test will still be ordered as a matter of routine, not selectively administered after careful discussion with patients. Colonoscopy will remain the accepted primary method for colon cancer screening. Radiology centers will continue to offer lung cancer screening to people who are unlikely to get lung cancer.
Why? Health care critics are quick to point to the profit motive. And it’s true that gastroenterologists, radiologists, urologists and physicians of all stripes make money from procedures that may not be necessary. But the real obstacle is not money. It’s the culture of doctors, and that will be very hard to change.
In medical school, I was given textbooks and made to memorize long lists of obscure facts, most of which have never come up in practice. Then I sat at the knee of master doctors. I followed them around. I learned to emulate what they did and how they thought. Over the years, I gained some approximation of their mastery. At times, I’ve even found myself mirroring how they stood and leafed through a patient’s chart.
Subtly, and then overtly, I learned that as long as I trusted my instincts, I was probably going to be right. Because doctors know best.
Ours is a comfortable hegemony, particularly if you do not question it. It has teeth, too. A strong defense to a malpractice lawsuit is that you did what other doctors in your community would have done — the “community standard” test. Citing anodyne research written by faraway experts to back up your actions is a less preferable strategy.
Against the gravitational pull of doctor-knows-best culture, research studies that fail to confirm current practice often have surprisingly little effect on our behavior. Guidelines written by academic types only impact the fringes of our practices. And despite the apparent move toward evidence-based medicine and comparative effectiveness research, most of us still feel that our own experiences and insights are the most relevant factors in medical decision-making.
You really see this tension in cancer screening. Doctors who want to prevent cancer apply these tests as if they were treatments, as if getting a mammogram were somehow like prescribing an antibiotic. Our experience tells us these tests catch cancer in some patients — the woman in the exam room could be one of them. Complications can be handled. We’ve all handled them before.
But this is where our reliance on our instincts and experience may betray us. Screening involves a test conducted on a healthy person, not a treatment given to a sick person. It’s comparatively easy for a doctor to see whether a treatment is working; that data point shapes our instincts and informs our experience going forward.
Screening is far less instructive for physicians. We can never tell how often a test makes an individual better or improves her prospects of survival. Neither is it possible to measure the effect of screening in your own practice. You must screen hundreds of patients to prevent a handful of cancer deaths. With routine mammography, you’d have to screen more than 1,000 women in their 40s to prevent just one breast cancer death.
Relying on individual doctors’ judgments regarding whom to screen has already had bad consequences. A majority of cases of cervical cancer today are in women who have not had adequate Pap testing, even though we’ve had that test for more than half a century.
It is time for us to own up to our shortcomings in cancer screening, and we must start by acknowledging a hard fact: Doctors sometimes don’t know best. We are terrific at inventing new tests that can be performed on people. But we have been less good at figuring out which people should have them.
Peter B. Bach, M.D., a senior adviser at the Centers for Medicare and Medicaid Services from 2005 to 2006, is the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center in New York.
I realize this article on
I realize this article on routine screening has been brought up before, but I found several interesting points which hit home with me and some new perspectives which I did not consider.
We learned that sigmoidoscopy is a cheaper, easier and effective alternative to colonoscopy for colon cancer screening.
My mom had a sigmoidoscopy which was not only a horrible experience for her, but it did not detect her cancer. The following year she had a good portion of her colon removed. She confronted the doctor who performed the sigmoid; he just shrugged his shoulders.
Regular mammograms aren’t necessary for women in their 40s and are needed only every two years for women ages 50 to 74, the United States Preventive Services Task Force has decided. For many women, Pap smears are required only every three years, not every year, the group also says now.
That is fine and dandy for a good portion of society, but if you are the one person whose cancer is missed then you are pretty much screwed.
Unfortunately a lot of these decisions about testing are based on the masses. Medicine is no longer (or was it ever) based on the individual. MOST women in their 40’s may not require a mammogram, so I guess we just hope we are a member of the masses.
I don’t disagree with the recommendations, but there should be some leeway; the patient’s thoughts regarding the matter should be considered.
Many doctors, maybe most, will ignore these findings and keep doing what they have been doing all along.
Why? Health care critics are quick to point to the profit motive. And it’s true that gastroenterologists, radiologists, urologists and physicians of all stripes make money from procedures that may not be necessary. But the real obstacle is not money. It’s the culture of doctors, and that will be very hard to change.
It has been brought up several times that the US over tests, because of docs who are in fear of getting sued. To a certain extent those were my feelings too.
I found this other perspective, the culture of doctors, interesting.
In medical school, I was given textbooks and made to memorize long lists of obscure facts, most of which have never come up in practice. Then I sat at the knee of master doctors. I followed them around. I learned to emulate what they did and how they thought. Over the years, I gained some approximation of their mastery. At times, I’ve even found myself mirroring how they stood and leafed through a patient’s chart.
This reminded me of something a user recently said regarding how doctors learn in medical school. I wonder if they are learning the best way. I really couldn't say if there is a better way.
What hit home with me was a time I was getting a pap from a student at a teaching facility. She looked about 2, but was most likely around 20ish.
We were just shooting the breeze with my legs in the stirrups and a tissue over my privates before the doctor came in. I was very saddened by some comments she made about hysterectomies. I could tell she was mimicking the sentiments of the older doctor who looked to be in his late 60’s. Hysterectomies seem too often to be the solution when they are not necessary and this philosophy is being passed on from generation to generation.
I seriously wanted to give her the name of a doctor she should follow around in order to get another perspective.
#1. I believe that the major
#1. I believe that the major reason this happens is because it is a lot easier for doctors to do whatever the patient requests.
I remember a patient coming with a shopping list: "I want a stress test, a PSA, and a chest x-ray." It took me 1/2 hour explaining to him that he needed none of these tests because he was low risk for heart disease, that the PSA is a terrible screening test, and a "routine" chest x-ray would expose him to radiation with little or no benefit.
He never came back. He probably found another doctor who figured it was a lot easier to do as the patient asked. He'd end up making the same amount of money taking 30 seconds to sign the requisitions as he would taking 1/2 hour doing what was best for the patient.
Most doctors don't like confrontation and potentially losing patients.
#2. Another reason - many people believe that more is better. And that if they are not getting what their friends are getting, then it means they have inferior care
#3. There are doctors who don't keep up with the latest studies and clinical practice guidelines
I would be surprised if a
I would be surprised if a great many patients come in with a list demanding tests and that would be a major factor determining the number of screenings performed.
What I found unique about this article compared to others which discussed routine testing recommendations was the focus on the culture of doctors, their medical school training and “habits” they pick up from following around other doctors during their training.
Ours is a comfortable hegemony, particularly if you do not question it. It has teeth, too. A strong defense to a malpractice lawsuit is that you did what other doctors in your community would have done — the “community standard” test. Citing anodyne research written by faraway experts to back up your actions is a less preferable strategy.
The “community standard” just cannot be denied. Doctors could take a little responsibility for their actions rather than just blaming the patients.
I agree with the recommendations to do less by the way. I was very apprehensive when I got my first mammogram as I felt I was exposing myself to unnecessary radiation, as opposed to just exposing myself to the technician.
It is very common for
It is very common for patients to ask for tests to be done, usually on the recommendation of a friend or celebrity. The two most common are the PSA and stress test.
Ditto - I usually have a few
Ditto - I usually have a few "lists of things for the doctor to order" presented every day. I always manage to refrain from asking "do you want fries with that?", but honestly, it does go through my head and I usually smile and I'm sure patients wonder why.
I try to use each as a teachable moment and review the evidence and rationale for not using diagnostic tests (ie stress tests) or disease monitoring tests (ie CEA for colon cancer and CA125 for ovarian cancer) as screening tests. I try to stress the importance of and good evidence for prevention (ie. weight loss, diet, exercise/physical activity, BP control, stress management, smoking cessation etc). I have clinical practice guidelines (in patient friendly terms) on my walls so patients can review while they wait for me (ie - colon cancer screening, who really needs a bone density test, mammogram recommendations). I hope that I am educating people that a preventative vs a diagnostic/curative approach is the way to go.
NB - I am talking about asymptomatic people with NO worrisome symptoms that need Diagnostic investigation. That's where people get confused. I can get a stress test in two days for what I think is Unstable Angina. I won't request a stress test for a healthy 45 year old with no risk factors, no symptoms, and no family history. If they don't agree with my explanation and insist, I will refer them to the extremely long waiting list of one of my cardiology colleagues to do the consult/risk stratification and then tell them they don't need a stress test. (But I also ensure they know to call me should they develop any symptoms - that's a whole different matter.)
Well, I am
Well, I am surprised.
However, one might look at a patient who comes in with a list as a very conscientious, well organized patient rather than demanding, ignorant and the root of all the evils of unnecessary screening.
I wish at a much earlier age I had my hormone levels checked, so I could see how they have changed over time. Not because I necessarily need that information, but just out of curiosity. I am pretty sure my doctor would not have judged me had I made such a request.
I hate to think my doctor is silently mocking me.
Can’t we just be curious about what is going on with our bodies?
I remember asking our pediatrician about the blood type of our children. I thought the information may be in their charts. The doctor went on and on about how it didn’t matter, if they were in an accident and needed blood they would check it at that time......... I just sat there in shock as he went on and on. I was just curious for goodness sakes. He completely misunderstood and jumped to conclusions as to why I was asking.
I realize my examples are not screening types, but were the only ones I could think of which related to my experiences.
It’s interesting to hear the perspective of doctors.
I can see the potential of people watching the doctor shows on TV and then calling their doctors for tests. I gather that is what you meant by “the recommendations of a celebrity”.
Twain wrote: #1. I believe
#1. I believe that the major reason this happens is because it is a lot easier for doctors to do whatever the patient requests.
I remember a patient coming with a shopping list: "I want a stress test, a PSA, and a chest x-ray." It took me 1/2 hour explaining to him that he needed none of these tests because he was low risk for heart disease, that the PSA is a terrible screening test, and a "routine" chest x-ray would expose him to radiation with little or no benefit.
He never came back. He probably found another doctor who figured it was a lot easier to do as the patient asked. He'd end up making the same amount of money taking 30 seconds to sign the requisitions as he would taking 1/2 hour doing what was best for the patient.
Most doctors don't like confrontation and potentially losing patients.
#2. Another reason - many people believe that more is better. And that if they are not getting what their friends are getting, then it means they have inferior care
#3. There are doctors who don't keep up with the latest studies and clinical practice guidelines
Twain makes excellent points.
I should note that physicals are quite time consuming, and do not result in a money making endeavor for the family doctor. That much more so when the patient comes in requesting tests that are not indicated, and (if ordered) will likely generate false positive results that will require chasing with painful and invasive procedures for the person.
"However, one might look at a
"However, one might look at a patient who comes in with a list as a very conscientious, well organized patient rather than demanding, ignorant and the root of all the evils of unnecessary screening."
I hope I didn't imply that people were demanding or the root of all evils - as I said, I see it as a teachable moment. I appreciate patients who are conscientious and responsible for their health - I don't like it when people say to me "you decide, you're the doctor". I prefer coming to an understanding and a plan that is mutually agreed upon based on the best information I can provide to the patient. I would never deny a necessary screening or diagnostic test but in the interest of fiscal responsibility, I don't feel that I "have" to order unnecessary things to keep the customer happy.
"I hate to think my doctor is silently mocking me."
Mocking is a strong word and perhaps you misunderstood me. My little mantra helps me to smile as I enter into the conversation instead of getting irritated when it's the 10th time I've had the interaction that day. I am only human.
Woodland Minas wrote: "...I
"...I always manage to refrain from asking "do you want fries with that?"
Oh how I would love to see the physicians on this forum,
partner a clinic. I'd bet on a long wait time to get in!
Woodland Minas
"However, one might look at a patient who comes in with a list as a very conscientious, well organized patient rather than demanding, ignorant and the root of all the evils of unnecessary screening."
I hope I didn't imply that people were demanding or the root of all evils...
No, you did not make that implication. It was a slight exaggeration on my part based on what I feel often occurs from doctors on the forum, putting the blame on patients.
The emphasis in the article was on doctors not on patients.
I happen to have a great deal of respect for Dr. Bach and was hoping points in the article would be addressed, but came to the conclusion that those of you who responded simply disagree with him which is fine. I always appreciate anyone who takes the time to read and respond to a posted article.
"I hate to think my doctor is silently mocking me."
Mocking is a strong word and perhaps you misunderstood me. My little mantra helps me to smile as I enter into the conversation instead of getting irritated when it's the 10th time I've had the interaction that day. I am only human.
I agree. Mocking was not the best word choice and came across a little harsher than I had intended.
I think you have an excellent attitude and sense of humor which are very important qualities when dealing with the public.