Step Away From that Test

My best friend turned 57 in October (but you’d never know it by looking at her; she doesn’t look a day over 45). Like most of us of a certain age, she has a few medical issues. Years of working as an editor has left her with carpal tunnel syndrome. Years of living with cats has left her with asthma. Years of sun worshiping behavior has left her with basal cell skin cancer. Years of good eating have left her with a borderline high LDL level. And, as a result of being, well, 58, she has a pain in her left shoulder. Sound familiar?

My friend recently switched doctors and found a new primary care physician who, upon hearing her medical history and current concerns, performed and ordered several tests, including:

— A pelvic exam/Pap

— A routine physical

— A baseline EKG

— A complete fasting blood panel, including a special test that measures LDL-particles (LDL-P)

— A mammogram and an ultrasound on her right breast, because the doctor felt a suspicious tissue mass (my friend has a family history of breast cancer)

— A right carotid artery ultrasound based on a bruit,  the swooshing sound the doctor said could indicate plaque

— A pelvic ultrasound and transvaginal ultrasound to check my friend’s uterus and make sure there was no hyperplasia since she was still having what seemed like periods

— A bone density scan

Total out-of-pocket cost to my friend (who has a high-deductible health plan): $1,900.

Now, some of these tests were warranted, such as the pelvic exam/Pap, mammogram and breast ultrasound. But, although I’m not a doctor, I would have questioned a few others.

• Why did she order a pelvic and a transvaginal ultrasound? The transvaginal gets the ovaries, uterus, and fallopian tubes and would pick up on any changes in the endometrial lining that might be of concern. What did the abdominal ultrasound add?
• Why did she order the LDL-P test? A study published in 2007 in the Journal of the American College of Cardiology found that it does not predict coronary artery disease in health individuals and should not become part of routine practice. Another article I found recommended it just for patients who are resistant to cholesterol-lowering drugs to diagnose a secondary cause for the high LDL, such as insulin resistance. For the record: although my friend’s LDL had been high in previous years, this time it was the lowest it had been in 20 years.
• Why did she order a carotid artery ultrasound? The American Academy of Physicians, as part of the Choosing Wisely Initiative designed to reduce unnecessary testing, says it should not be performed in asymptomatic people. Plus, my friend doesn’t have any risk factors for stroke.
• Why did she order a bone scan? It is not cost effective or needed in women younger than 65 with no risk factors. My friend never smoked, is not underweight, had not had any unusual fractures, does not have a family history of osteoporosis, and exercises regularly. The scan showed some osteopenia in her wrists (pre-osteoporosis) so the doctor recommended my friend take calcium + vitamin D daily and do weight bearing exercises–which is what she should be doing anyway.
• Why did she order an EKG? The Choosing Wisely initiative says there is no reason to order an EKG for someone with no cardiovascular symptoms, ie, chest pain or shortness of breath.

Redundant and unnecessary tests are a major contributor to the bloated cost of health care in this country. The American Board of Internal Medicine, which began the Choose Wisely initiative, estimates that a third of healthcare costs in this country are related to unnecessary tests and procedures.

Indeed, a study published in the journal Health Affairs in 2009 found that  eliminating redundant tests in hospitals would have saved more than $8 billion in 2004 alone, nearly 3 percent of all inpatient costs.

Take a look at the Choosing Wisely web site. To date, the nation’s leading medical specialty societies have identified 90 tests and treatments we and our doctors should question. Print out the  list or download it to your phone and the next time your doctor orders a test or treatment, whip it out and ask the most important one-word question you can ask: “Why?”