Danielle is a 21-year-old woman with a headache. Her doctor tells her that she needs a CT scan and a spinal tap. Danielle doesn’t want these tests; she knows that she drank too much last night and feels like she has a bad hangover, but should she really say no to her doctor?
Nancy is a 38-year-old woman with vomiting and diarrhea. Her toddlers have the same symptoms. The doctor says she needs to get a CT scan of her belly. He says her blood pressure is “borderline high” and that she should also start taking medication. She’d prefer to avoid drugs if possible-what should she do?
As an emergency physician, I see dilemmas like these every day, yet they get very little attention. For so long, the rhetoric has been about the danger of too little medical care. Newspapers are full of stories about deaths that have resulted from missed diagnoses and lack of access to care. TV shows glorify the detective-doctor who doesn’t give up and persists on ordering test after test in order to solve an esoteric case.
While many people still lack access to care, there’s mounting evidence that many people also receive too much care. The prestigious Institute of Medicine estimates that 30 percent of all medical tests and treatments are unnecessary. This is not only wasted money-an estimated $700 billion of unnecessary spending per year-but also potentially harmful. Every test has risks and possible side effects. A CT scan has a risk of radiation, for example, that may lead to cancer later in life. And one test often leads to another, even riskier, test.
There are many causes of overtreatment. Drug companies and technology manufacturers have their own incentives for wanting people to receive more, rather than less, care. While doctors generally mean well, they also have financial incentives for over-testing.
A study in the New England Journal of Medicine found that 94 percent of doctors have some relationship with a drug company or medical device company, and many are paid more for conducting more tests. On top of that, fear of malpractice can also drive doctors to do more, just to be sure.
The problem isn’t just doctors, though. Patients also believe that more is better. New tests and treatments succeed in part because the general public tends to idolize technology. Unfortunately, this issue is complicated because medical advances can be helpful and save lives in certain circumstances. So how do you know when testing is appropriate-and when it’s simply too much?
There isn’t an easy answer to this question, but I recommend that you ask your doctor five key questions every time he or she recommends you undergo a test:
What do you think my diagnosis might be?
Your doctor always has some sense of possible diagnoses before you get any tests done. You should find out what he or she is thinking; that way, you know why the tests are being done and how likely the various possibilities are. If Danielle had asked her doctor this, for example, he likely would have told her that odds are she just has a hangover and that it’s far less than a 1 percent chance that she has brain bleeding.
What evidence exists suggesting this test or treatment is beneficial?
This is particularly important for screening tests like checking for high blood pressure, cholesterol, and cancer. Ask your doctor what studies there are to show that a test improves quality of life. If there is no evidence for the test or if the jury is still out, you should ask why your doctor thinks you need the test and keep in mind your doctor’s possible incentives for testing and treatment.
What are the potential side effects?
Every single test, even just getting your blood drawn, has side effects-and you should know what they are before you consent to any tests. Without knowing the side effects, you can’t weigh the risks against the benefits.
Is watching and waiting an option?
Very few situations are so urgent that a test has to be done ASAP; most of the time, it’s perfectly fine to wait and see if other symptoms emerge or if you get better. With Nancy, for example, it would have been appropriate for her to go home and see if she gets better; she didn’t need to get a CT scan right away.
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What other treatment options do I have?
Doctors are trained to “fix” problems with treatments. Many of us don’t have the knowledge or time to counsel patients on other options, like diet and exercise changes and/or alternative treatments. But these other treatments may be just as effective and may help you avoid potentially harmful side effects. Perhaps Nancy’s blood pressure could be controlled with diet alone, for example. There are always alternatives; ask about them.
Ultimately, you should have a trusting partnership with your doctor and feel comfortable asking hard questions. You are your own best advocate, and you have to speak up to make sure you get the right medical care-and avoid unnecessary tests and treatments.