Tuesday, April 14, 2015

Your call: Overdiagnosis or appropriate caution?

In a Medscape article, Kenny Lin (a family physician at Georgetown University School of Medicine) asks, "Can Patients Understand the Concept of Overdiagnosis?" He suggests:

In my opinion, doctors are not doing nearly enough to inform patients about the possibility of overdiagnosis, and we really need to do more. One survey of people aged 50-69 years found that only 9.5% of patients were told about the possibility of overdiagnosis when cancer screening was discussed. Given the results of another survey that shows that patients' tolerance levels for overdiagnosis can vary widely, it is absolutely essential that we include a discussion of overdiagnosis in shared decision-making about cancer screening.

I had an experience that might illustrate the difficulty of discussions about this topic.  A recent CT scan picked up incidental findings in my lung.  The radiologist reported as follows:

New left lower lobe peribronchiolar opacities and right lower lobe 5 mm nodule from 2013, which may relate to aspiration/infection. Since these findings are unable to be visualized on the scout images, follow-up chest CT in 6 weeks is recommended to document resolution.

With the concurrence of my primary care doctor--who is passionate about avoiding over-testing--a follow-up scan occurred a few weeks later, when an aspiration or infection would likely have a chance to clear up. There was good news:

Non-contrast chest CT was performed acquiring sequential axial images from the thoracic inlet through the adrenal glands. Thin section axial, coronal, sagittal and axial MIP's were also obtained. 

There has been substantial interval clearing of previous bilateral lower lobe ground-glass opacities. There are no new ground-glass opacities, consolidations or nodules. No endobronchial lesion or pleural abnormality is identified. 

IMPRESSION: Resolving bilateral lower lobe aspiration or infection. 

Here's the question for my medical experts reading this.  I'm not asking you to second guess my PCP's judgment. I'm asking whether you, in your clinical practice, would have judged the initial findings worthy of the second CT scan, with the added radiation exposure? (Here there was no personal or family history of lung disease.)

More importantly, whichever way you lean on this question, how would you address Dr. Lin's point, i.e., how would you discuss the pro's and con's of the additional diagnostic testing with your patient?


Barry Carol said...

As both a patient and an observer of the healthcare system from a market and economic perspective, I see two issues here.

First, the doctor may be thinking about the consequences of being wrong in a litigious society if he doesn’t order the test and cancer is, in fact, present but isn’t discovered until later. He fears a failure to diagnose lawsuit which, if it went to trial, the notion that a test wasn’t ordered because it saves money for the system and evidence based guidelines didn’t call for it wouldn’t carry much weight with the jury. If the perceived standard of care in the region is to order the test, he may feel he has no choice but to order it whether he thinks it’s necessary or not.

Patients, for their part, generally like testing or at least don’t mind as long as the test isn’t invasive or painful and someone else, namely an insurer or taxpayers, will pay for it. They think more care is better care even when it isn’t and they equate more rather than less testing with thoroughness.

I don’t see how this changes until we get safe harbor protection from failure to diagnose lawsuits for doctors who follow evidence based guidelines and protocols where they exist. The patient perception problem can be addressed by shifting financial liability for testing when the evidence doesn’t call for it from insurers and taxpayers to patients.

Bruno DiGiovine, MD said...

I think the question of whether repeat CT is appropriate really depends upon your symotoms. If you had symptoms of an infection when the first CT was done and these symptoms resolved, I would not repeat the CT. A follow-up CXR (or no imaging at all) would be sufficent. If the two conditions above were not satisfied, I think repeating the CT is appropriate. Whether the first CT was appropriate is a different question which we do not have sufficient information to judge.

I do not believe that the threat of lawsuits is relevant but that is probably a different discussion.

Andrew Brown said...

It is an interesting question. As a radiology resident my first thought is what was the clinical indication given to the radiologist? If the requisitions simply says "rule out cancer" then suggesting a follow-up may be reasonable. Without a clear history it can be tough to provide insightful recommendations. If I'm given the clinical context, my impressions I often say "follow-up CT is recommended if symptoms persist." In this way the referring physician is free to use their clinical judgment.

e-Patient Dave said...

It's a shame this is posted during the HIMSS health IT conference, during which a lot of smart docs I know are all tied up. Might want to raise this again next week!

e-Patient Dave said...

btw, separate from my other comment about docs -

MY view is that the REAL issue is that a lot of medicine has to be done in UNCERTAINTY. A lot of the time we really don't know.

The appropriate thing to do, in those situations, is list what we do know, size up the pro's and con's, and choose. For instance that's how my PCP handled the discussion about "You're at the age where we should think about prostate testing. There's really no sure answer. The test isn't all that accurate, and even if ... " etc etc.

I've seen so much strife that arises for both docs and patients because culturally we both expect docs to be perfect. (And I know a lot of that is beaten into residents by other docs - so I've been told many times. It's self-perpetuating.)

Imagine this whole conversation if everyone everywhere really "got" the uncertainty thing.

It's not unlike the situation with my brother the Mercedes mechanic who died last year. He could fix just about anything, but sometimes you'd ask him something and he'd just laugh and shrug and say "Hell, I dunno..." and laugh again.

Not allowed to do that in medicine, it seems. But my doc does, and I know a lot of others do.

Fasial Abdulkader said...

A very interesting question to a very routine situation we as doctors deal with on a daily basis.You could actually write a whole book about it and am not sure it will give you a clear answer !!

In my humbled opinion there are two points to consider here:

1. I need to protect the patient and so I need to know what is the calculated risk of these findings and the whole clinical picture to represent a cancer? if the answer is high then indeed doing further investigations and procedures is mandatory. However, what if the risk is quiet small and these findings represent lets say <3% (i.e 97% chance its not cancer) what shall we do here as doctors? Well in general we tend to follow international guidelines regarding that issue. The next question here is how accurate are theses guidelines, protocols, evidence based medicine are?????and if they are that accurate why do they keep changing and being updated?????these questions I faced personally from patients, and I pose them as well, as if I was the patient. Now I had cases where the risk of having cancer were very small and the guidelines and the whole clinical picture and my experience tells me to reassure these patients, yet to my surprise be proven later as cancer cases!!!!

The answer in these situation is really to involve the patients in the decision making process. This means a lot of information and long multiple consultations to come to agreement.

2. Protecting ourselves from legal actions. Again in many situations staff regardless of their role and responsibilities face an investigation or inquiry regarding their actions. Now that process is so stressful and SCARY that many staff would choose actions to protect themselves, even if that COULD BE not in the patient interest. For example, lets say a patient with a small mass that the clinical picture and the international guidelines indicate no further investigation is needed and just observe for now.However, the patient is extremely worried and after long discussions and consultations wants it to be further investigated. Now lets say the investigation was CT guided biopsy, which is a very safe procedure in general and the patients is aware of all the risks the procedure carry. First of all the doctor here, could face questions from the hospital for ordering such an investigation, or the patient could develop a complication from the investigation and the cases will be under the "Root Analysis".

Again I believe involving patients in the decision making process and gaining their trust, will protect me as staff from anything. BUT can we always gain the patients trust?