My father is 92 years old, and I am beginning to wonder whether the best thing for his health would be to stay away from doctors. That’s because well intentioned physicians often expose their elderly patients to harmful and unnecessary services out of habit. That’s certainly the message I absorbed after reading a recent issue of JAMA Internal Medicine that published three studies documenting the worrisome frequency with which internists like me over-test and over-treat our patients. I am going to briefly describe these three studies before laying out some ideas about what’s going on here.
One study explored the use of PSA screening among men with limited life expectancy. The PSA blood test is used to screen men for prostate cancer. The test is controversial, with some groups saying there is no evidence it benefits anyone and others saying it is a crucial way to reduce prostate cancer deaths. Despite this controversy, almost everyone agrees that when people have limited life expectancy–when, because of age and other illnesses, they probably have fewer than five years to live–the PSA test does more harm than good. But some physicians nevertheless continue to order PSA tests, even in men close to the end of their lives.
The study, which analyzed data from Veteran’s Affairs medical centers, found out that patients receiving care from “attending physicians”–more senior physicians–were more likely to receive harmful PSA tests than patients receiving care from physicians still in training. Indeed, 40% of patients expected to live five or fewer years received PSA tests from experienced physicians, versus only 25% receiving care from trainees :
The second study looked at carotid artery imaging in people 65 years or older. The carotid arteries are the large vessels on either side of your neck, the ones you can feel your pulse on. They are the main supply of blood to the brain. People who get blockages in their carotid arteries are at risk for strokes.
Carotid imaging with tests like ultrasound can identify narrowing of these important arteries, potentially revealing partial blockages in time to fix them before they fully occlude. In the old days, I’d place my stethoscope on a patient’s neck to listen to the harsh sound of blood squeezing its way through these blockages. Upon hearing a worrisome whoosh, I’d send my patient for imaging and then, if my suspicions were warranted, would refer the patient to a neurovascular surgeon, who would decide whether to perform a procedure to open up the artery.
But now, we physicians are being told to be more cautious. The benefits of all these tests and treatments aren’t so clear in many patients. The risks of the surgery can outweigh the benefits in people with no history of stroke or stroke-like symptoms. Nevertheless, many physicians continue to test and treat aggressively.
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