The Benefit of the Useless

Katie is 51 years old and an eight-year survivor of breast cancer.  Katie is almost certainly cured.  Her physical exam is benign. Her mammograms are normal.  She feels healthy.  However, she sees me every three months and insists I order a useless blood test.  To my shame, I must admit, I order it every time.

The test is an ESR  … Erythrocyte Sedimentation Rate.  This is a test of inflammation which is used to monitor infections and autoimmune disease like Lupus.  Katie has never had either of these conditions.  She read in some online chat room a couple of years ago about the need to monitor her immune system.   Katie insists on checking her ESR four times a year as “protection” against her breast cancer.

I have met with Katie and explained the lack of benefit of this test for her condition.   I have advised that even if her cancer returned, the ESR would not change.  Nonetheless, she gets great comfort from her normal ESR test.  Fortunately, it is inexpensive ($18).  It also does not require exposure to radiation or other injury.  However, I feel guilty that I have been unsuccessful in educating Katie to the point that she will even decrease the frequency of this falsely reassuring number.   Katie’s ESR dependency symbolizes the problem in reducing unnecessary testing for health care in general.

Medicine is full of better-known examples of useless and wasteful testing.  PSA and CA125 cancer markers that fail as screening tests.  Analysis indicates they cause more harm than benefit.   MRIs for muscular back pain, which will go away by itself.  Unneeded EKGs, stress tests and cardiac catheterizations, instead of thoughtful conservative medical management.  CT scans often take the place of sound clinical analysis and judgment.   A 15 yr study of 30.9 million-radiology imaging exams published recently shows a tripling in the last 15 years.

These unneeded tests do more than waste dollars.  If a test is not necessary and has no medical benefit, it can only cause harm.   The test itself can cause problems such as excess radiation exposure, allergic reactions and discomfort.  In addition, tests find false positive results, which lead to further useless testing or unneeded treatment.

We must move toward a standard of healthcare in this country which is not only inexpensive, but of the highest quality.  We must solve the problem of the Katie’s who demand unneeded tests and doctors, like me in this case, who are ordering these studies.

The solution will be in two parts.  First, there is the need for a universal consensus of medical data.  We need to do the research which defines which testing really helps, as well as which tests are unneeded and perhaps dangerous.  Doctors and patients must move beyond the vague concept of “the art” of medicine in making decisions. We must base plans on cold hard research.

Nonetheless, the art of medicine is the key to the second part of the solution.  The art of medicine is critical compassionate communication.  Doctors must take research-based decisions and explain carefully to patients why some tests are beneficial, some harmful and some just waste.  Doctors must avoid the “easy” way of simply ordering a test to assuage a patient’s anxiety.  This does more than produce useless results, confused patients and eventual medical harm.   Unneeded testing interferes with the physician – patient relationship as it takes the place of good education and discussion.

We must never order a test unless we understand exactly how we will interpret the result. We must never order a test unless we have a plan about what we are going to do with the result.   We must never order a test unless we are going to do something with the result that will improve that patient’s life.   We must demand research that shows the complete risk and benefit of each test.

Katie will be in the office again next week.   I promise to try again to explain that the ESR, in her case, is medically useless.  I will try to replace this test crutch with knowledge, reassurance and hope.   Maybe it will help us to understand each other a little better.

 

4 Comments

  • D. Lane
    In my opinion, your patient should have the right to order whatever tests she likes to monitor her condition - as long as she is willing to pay for it.
    • James Salwitz, MD
      In the real world that is what often happens. However, technically patients can not write medical orders at all. Only doctors can order tests or treatments. Patients can request tests/treatments, or they can refuse tests/treatments. The problem I am trying to get at is that when we order medical care that can not help, in the end it can only hurt ... either directly, or by giving false reassurance. Thanks, jcs
  • Pat Fleming
    I so much enjoy your blog. I understand your attitude towards ordering this test for Katie's piece of mind yet i can understand her fears and empathize with her fears of her past medical history. An ESR is an inexpensive blood test that somehow does give her some re-assurance that she is searching for.On the other side of the fence is the the old question "Just where do you draw the line". My personal opinion is that if you refuse to order the esr,she WILL find another doctor who will order it for her. It's a "Catch 22" situation.You are trying to do one thing right and she is going to continue to be insistant to find her inner peace.Have a good day!!
    • James Salwitz, MD
      You are almost certainly correct. The challenge of the ongoing healthcare "conversation" in this Country will be to balance individual perceived need with provable medical care. People do not always want what is good for them, but they must have the choice. Thanks for your comment. jcs

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