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'More is better' has been a common theme in American medicine for years, as patients have been urged to get their annual physical checkups and undergo certain screening tests at certain stages of life. Such thinking has been regarded as the basis of sound, preventive medical care. Now, that thinking is beginning to change.
The question of what tests patients should have has become an important -- and controversial -- topic in health care, with different studies suggesting conflicting advice about such screenings as mammograms, prostate tests, and even the annual physical examination.
“For most medical issues,” says Michael Barry, M.D., president of the Informed Medical Decisions Foundation in Boston, “there is more than one reasonable way to proceed, whether it is for a test or treatment. More isn't always better. Sometimes it is, but we think patients should have a voice in those decisions.”
Indeed, Dr. Barry’s organization exists, he says, “to inform and amplify the patient’s voice in health care decisions so that good medical decisions are made with the full participation of an informed patient.”
Dr. Barry, who also practices primary care and serves as the medical director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital, discusses this new approach to medical testing and treatment as a guest on the April edition of Physician Focus with the Massachusetts Medical Society. Hosting this edition is primary care physician Mavis Jaworski, M.D.
The notion that we test and treat too much, sometimes unnecessarily, isn't new to health care in America. Many patients, for example, would want an expensive test to be sure that the severe headache they are having isn't a brain tumor. Others ask for antibiotics when those medicines will have no effect. Many physicians admit to practicing ‘defensive medicine’ -- ordering tests and treatments to protect themselves in the event of a malpractice lawsuit. As health costs have soared, more attention has been given to the frequency and kinds of testing and treatments. But the concern now is more than just about spending too much.
“It’s not just about medical care costs,” Dr. Barry emphasizes, “it’s about harm. Each test or treatment can have potential downsides as well as upsides. If we do tests or treatments in the wrong circumstances, we can be doing more harm than good.”
One example cited by Dr. Barry is the PSA blood test for prostate cancer. The reliability of the test has been called into question, and while it can detect cancers, many of them it does spot may not be harmful. But the findings can lead men to decide to have surgery or radiation that can have considerable side effects, possibly lasting for years.
“The key part to providing better care,” Dr. Barry says, “is to strip out the tradition-based medicine and focus on the evidence-based medicine.”
Dr. Barry urges patients to speak up, to ask to be part of the discussion about their own care. “It’s ultimately their health,” he says. “They are the ones who will have to live with the consequences of the decisions. It’s really important for the patient to speak up.”
And what about physicians? How do they adapt to this changing style of care, especially when most are rushed and don’t have the time they’d like to have to see and talk to patients?
He suspects physicians want to be able to give their patients more time and urges them to invite their patients to participate in the discussions and to learn what their patients care about and what their preferences are.
“Shared decision-making is a two-way street,” he says.
Watch the above video for the full discussion, including conversation about patient decisions aids offered by the Informed Medical Decisions Foundation, the three steps used to measure success in shared decision-making, how patients can determine the validity of health information, and the Choosing Wisely campaign, an effort by medical providers that promotes conversations between patients and physicians about unnecessary medical tests and treatments.
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MMS/Richard Gulla
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