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Why It’s So Tempting To Over-screen: A Personal Perspective

Health screening is part of good preventive care, though over-screening can lead to increased costs, and potential patient harm. Healthcare professional societies have recently developed excellent public service announcements describing the dangers of over-testing, and new research suggests that though additional medical interventions are associated with increased patient satisfaction, they also lead (ironically) to higher mortality rates.

And so, in a system attempting to shift to a “less is more” model of healthcare, why is resistance so strong? When the USPSTF recommended against the need for annual, screening mammograms in healthy women (without a family history of breast cancer) between the ages of 40-49, the outcry was deafening. Every professional society and patient advocacy group rallied against the recommendation, and generally not much has changed in the breast cancer screening world. I myself tried to follow the USPSTF guidelines – and opted out of a screening mammogram for two full years past 40. And then I met a charming radiologist at a women’s medical conference who nearly burst into tears when I told her that I hadn’t had a mammogram. Her lobbying for me to “just make sure I was ok” was so passionate that I simply could no longer resist the urge to get screened.

I knew going into the test that there was a reasonably high chance of a false positive result which could cause me unnecessary anxiety. That being said, I was still emotionally unprepared for the radiologists’ announcement that the mammogram was “abnormal” and that a follow up ultrasound needed to be scheduled. I must admit that I did squirm until I had more information. In the end, the “abnormality” proved to be simple “dense breast tissue” and I was pleased to have at least dodged an unnecessary biopsy or lumpectomy. Did my screening do me any good? No, and some psychological harm. A net/net negative but without long term sequelae.

My next personal wrestling match with screening tests was the colonoscopy. I was seeing a gastroenterologist for some GI complaints, and we weren’t 5 minutes into our conversation before he recommended a colonoscopy. I argued that I was too young for a screening colonoscopy (I was 42 and they are recommended starting at age 50), and therefore was doubtful that anything too helpful would be found with the test. My suggestion was that a careful history and some blood testing might be the first place to start. My gastroenterologist acquiesced reluctantly.

As it turns out the blood testing was non-diagnostic and my symptoms persisted so I agreed to the colonoscopy. In this case I felt it was reasonable to do it since it was for diagnostic (not screening) purposes. I was quite certain that it would reveal nothing – or perhaps a false positive followed by anxiety, like my mammogram.

What it did show was some polyps that had a 50% chance of becoming malignant colon cancer in the next 10 years. I was shocked. If I had waited until I was 50 to start screening, I could have missed my cure window. The uneasiness about screening guidelines began to sink in. As a physician I had done my best to apply screening guidelines to myself and resist the urge to over-test, even with a healthy dose of natural curiosity. Yet I failed to resist screening, and in fact, my life was possibly saved by a test that was not supposed to be on my preventive health radar for another 8 years.

Screening tests are recommended for those who are most likely to benefit, and physicians and patients alike are encouraged to avoid unnecessary testing. But there are always a few people outside the “most likely to benefit” pool whose lives could be saved with screening, and the urge to make sure that’s not you – or your patient – is incredibly strong. I’m not sure if that’s human nature, or American culture. But a quick review of Hollywood blockbuster plots (where tens of thousands of lives are regularly sacrificed to save one princess/protagonist/hero from the aliens/monsters/zombies) testifies to our desperately irrational tendencies.

I am now biased towards over-testing, because my emotional relief at dodging a bullet is stronger than my cerebral desire to adhere to population-based recommendations. Knowing this, I will still try to avoid the temptation to over-test and over-treat my patients. But if they so much as hint that they’d like an early colonoscopy – I will cave.

Does that make me a bad doctor?

High Deductible Health Insurance Plans Incentivize Patients To Skip Screening Tests

Almost half of health plans in the US have deductibles of at least $1,000 according to a new study.  It’s called “cost shifting” and it’s a big part of the future of American health care.

There are two major reasons why employers are doing this.

First, higher deductible plans are cheaper, since there is less risk to insure.  Think of your car insurance – why would you make a claim for a ding on your door when it’s cheaper for you to just pay to have it fixed (or fix it yourself)?  The higher the deductible, the lower the premium, even if it means more out-of-pocket cost for you for the small stuff.

Along these same lines is the second reason.  If employees spend more of their own money on health care, maybe they’ll be smarter about how they spend it.

It sounds good – but does it work?

Yes.  And No. Read more »

*This blog post was originally published at See First Blog*

When Less Is More: How To Improve The Quality Of Primary Care

On the NPR Shots blog, Scott Hensley writes, “Quality Prescription For Primary Care Doctors: Do Less,” about an article in the Archives of Internal Medicine. Excerpt:

“A group of docs who want to improve the quality and cost-effectiveness of primary care tinkered with some Top 5 lists for of dos and don’ts for pediatricians, family doctors and internists.

After testing them a bit, they published online by the Archives of Internal Medicine. Most of the advice falls in the category of less is more.

So what should family doctors not be doing? The Top 5 list for them goes like this:

1. No MRI or other imaging tests for low back pain, unless it has persisted longer than six weeks or there are red flags, such as neurological problems.
2. No antibiotics for mild to moderate sinusitis, unless it has lasted a week or longer. Or the condition worsens after first getting better.
3. No annual electrocardiograms for low-risk patients without cardiac symptoms.
4. No Pap tests in patients under 21, or women who’ve had hysterectomies for non-malignant disease.
5. No bone scans for women under 65 or men under 70, unless they have specific risk factors.”

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Cavernous Angiomas: Screening Of A Family Over Three Generations

Cavernous angiomas belong to a group of intracranial vascular malformations that are developmental malformations of the vascular bed. These congenital abnormal vascular connections frequently enlarge over time. The lesions can occur on a familial basis. Patients may be asymptomatic, although they often present with headaches, seizures, or small parenchymal hemorrhages.

In most patients, cavernous angiomas are solitary and asymptomatic. In recent times, increasing MRI has detected several such asymptomatic cases and has prompted a study into the genetics and natural history of this condition.

It is now known that cavernous angiomas have a genetic basis. Familial forms of cavernous angiomas are associated with a set of genes called CCM genes (cerebral cavernous angioma). This is a case report describing the phenotypic expression of a familial form of cavernous angioma.


A 54-year-old man was referred for an MRI of the brain with complaints of headache and seizures. A cranial CT scan revealed few hyperdense lesions. A subsequent cranial MRI scan revealed several lesions with features representing cavernous angiomas.

The patient was offered counseling and was treated conservatively. Genetic testing was not possible due to the high prohibitive cost. However, screening of the family members by MRI was recommended.

Cranial MRI of the immediate family members was performed. Four brothers of the patient and his mother were found to have multiple cavernous angiomas. The father, youngest brother, and his younger sister were found not to have any such lesion. Both children of the patient were also found to be free of these lesions. Incidentally, a meningioma was found in the father of the patient. Read more »

*This blog post was originally published at AJNR Blog*

A Video Poem: Medical Tests And What “Normal” Means

I’ve written a few times about Veneta Masson, a nurse practitioner who wrote in Health Affairs and the Washington Post about her decision to forego further mammograms despite the fact that she was in a higher-risk category.

Veneta is also a poet. She sent me a video animation of her poem “Reference Range,” which I’m pleased to share with you. I think the poem and the video are beautiful, touching on important issues of how meaningless numbers and scores may be, subject to misinterpretation. She writes:

I see no cause for alarm.

“Is it normal?” you ask.

Normal’s a shell game you seldom win.

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Latest Interviews

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Latest Book Reviews

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

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Eat To Save Your Life: Another Half-True Diet Book

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