Should You Listen to Your Doctor?

moneyWhen I speak about the US healthcare system, I always like to tell the story of my mother. A couple of years ago, she emailed my sisters and I. “Good news!” she wrote. “My nuclear stress test was normal!” (The test  involves injecting a radioactive dye into a vein after which a special camera scans the heart to determine if there are any blockages).

At the time, my mother was 70 and, with the exception of very-well-controlled high blood pressure (that she’d had all her life), extremely healthy. No sign of heart disease. No angina. No shortness of breath. In short, no indications for an expensive, invasive, potentially dangerous, test. So why, I asked her, did she have the test? “Because my doctor told me it was time,” she said.

At which point I began banging my head against the wall.

Even regular stress tests (where you run on a treadmill or ride a bike) are only recommended in people with heart disease or symptoms of heart disease, same with an EKG. Yet a survey of nearly 1200 people ages 40 to 60 with neither found that 39 percent had an EKG over the previous five years, and 12 percent underwent an exercise stress test. This could lead to false positives and more invasive testing.

I was reminded of all this after reading a study published in JAMA Internal Medicine last month. It analyzed conversations about cardiac catheterization to open blocked blood vessels and angiograms between cardiologists and patients with stable coronary artery disease (CAD). It found that few doctors ever discussed the evidence behind these procedures, while some “implicitly or explicitly overstated the benefits.” Doctors also minimized the risks and used technical terms that most of us couldn’t understand. When one patient expressed concern about potential risks (including kidney failure), the physician said: “Oh, don’t worry about that. I’ve been doing it [angiogram/PCI] for 8 years…[I] trained at a big institution.”

But get this: An analysis of eight studies involving 7,229 patients found these procedures don’t reduce the risk of heart attack or death any better than treatment with medications. Yet just two of the 40 doctors in the study told patients this. Even more disconcerting is the fact that although many patients in the study were not taking medications recommended for CAD, like statins, few of the doctors discussed their importance, even downplaying their role in preventing future problems.

So why the focus on invasive procedures rather than drug treatment? Same reason my mother’s doctor performed that nuclear stress test: They pay a  heck of a lot more that an office visit to prescribe medication.

As long as we continue with our wasteful fee-for-service reimbursement system, we will continue to be subjected to unnecessary, expensive treatments for which there is minimal evidence. Until it changes, we, as patients, have to be much more assertive in ensuring that we are receiving the right care at the right time.That means asking questions like: “What are the risks and benefits of this test/procedure?” and “How will the result change your treatment recommendation?”

One tool to use is Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation designed to “spark conversations between providers and patients to ensure the right care is delivered at the right time). It lists dozens of tests and procedures that are often unnecessary and even dangerous. In other words, it is designed help you ask questions and even challenge your doctor about recommended treatments. I highly recommend you check it out before agreeing to anything your doctor recommends.

Do you question your doctor about the necessity of recommended treatments?

 

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