How (and When) to Say ‘No’ to Your Doctor
In the 1950s, a doctor convinced my mother he could remove my sinus polyps with a brand-new, painless therapy: radiation. In those days, kids with adolescent acne were also getting radiation treatments. The polyps went away but the therapy was overkill. Much later, I learned that thyroid cancer is a possible side effect. Because of that experience and others, I’ve always thought that, except when I’m in dire straits, less is better when it comes to medical treatments.
Health authorities have finally begun to focus on the unnecessary cost and the risks of overtesting and overtreatment. Physicians are being warned, but it’s hard for patients to know what to do. Recently I came across a website called Choosing Wisely that lists scores of common screenings, procedures and medications that experts say should no longer be used routinely. I was shocked at how many unnecessary treatments I’ve had.
The website is the brainchild of the American Board of Internal Medicine Foundation (ABIM), which contacted more than 60 professional organizations that represent medical specialties—the American College of Surgeons, for example. ABIM asked each organization to identify at least five things both providers and patients should question because they’re done too often, though all are appropriate (or even life-saving) in the right circumstances.
The Choosing Wisely website is the result. It has two lists. The one intended for health care providers records, by specialty, how the medical organizations responded to the request from ABIM. The other list is meant for patients, and it links to reports that explain in plain language what’s no longer recommended for most people and why. You’re encouraged to print out pages to discuss with your doctor.
Going by what I’ve now read at the site, my own medical overreach (encouraged by doctors) has included quite a few treatments I didn’t need, such as the many times I took antibiotics for sinus infections. It seems sinusitis is almost always caused by a virus, not bacteria, and antibiotics are useless against viruses.
I’ve also had routine screenings I could have skipped. A decade or so ago, my annual Pap test suggested I might have a precancerous condition, so I had a minor surgical procedure. The hunk of tissue the doctor removed turned out to be perfectly normal.
The problem with screenings like Pap tests is that false-positive results—such as mine—can lead to unnecessary treatments, including surgeries. Since cervical cancer generally takes 10 to 20 years to develop, Choosing Wisely recommends that women at average risk have a Pap test only every three years. Those who are over 65 and have had several normal Pap smears don’t ever need to have another one.
I was pleased to learn that there are also other screenings most people can give up as they age. Those who have a life expectancy of less than 10 years—and have no symptoms, family history or other risk factors—can forget about routine mammograms, colonoscopies or PSA tests (for prostate cancer). But short of clairvoyance, how can you know what your life expectancy is, especially since, up to a point, the older you are, the longer you’re expected to live? You’ll find estimates of life expectancy at various ages at this website. The bottom line: the average man is down to less than a decade at about 77; the average woman, at around 80.
Of course, if you’re at risk for a particular disease—if it runs in your family, for example—a routine screening or preventive medication can be lifesaving. That’s why Choosing Wisely’s recommendations are intended only as starting points for discussions with your physician.
What do you do if your doctor recommends something you’re dubious about? For a number of years, I’ve had exercise stress tests: I walk on a treadmill, wired up to an EKG. This is a test often included in purely routine checkups. I do have a pacemaker but I have no other heart problems, and Choosing Wisely says these stress tests are less accurate for lower-risk people and can produce misleading results. I mentioned this the last time my cardiologist suggested the treadmill evaluation. After discussing it, we agreed that I wouldn’t have another exercise stress test unless I developed new heart problems or was contemplating major surgery.
It isn’t easy to question a doctor’s recommendation. On the other hand, it isn’t easy for physicians to question our strong opinions on what we need, either. More than half the doctors quizzed for one survey confessed that, if a patient urged them to provide a particular test or procedure, they would give in.
A quick look at Choosing Wisely and a discussion afterward could help both patients and doctors resist overtesting and overtreatment.
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The Silver Century Foundation promotes a positive view of aging. The Foundation challenges entrenched and harmful stereotypes, encourages dialogue between generations, advocates planning for the second half of life, and raises awareness to educate and inspire everyone to live long, healthy, empowered lives.
"It is not by muscle, speed, or physical dexterity that great things are achieved, but by reflection, force of character, and judgment; in these qualities old age is usually not poorer, but is even richer."
Cicero (106-43 BC)