When Good Medicine Goes Bad

May 12, 2010— -- Plenty of Hollywood dramas have a patient come in to a hospital for one problem, and in the course of their testing doctors find something horribly wrong -- cancer, for instance -- with that seemingly unnecessary test being the difference between life and death.

The story has appeal, but now a journal published by the American Medical Association is taking steps to highlight the perils of assuming that extra tests and treatments are always a good thing. Editors hope to spotlight the fact that those extra tests can often lead to unnecessary treatments or even hurt the patient.

"There just seems to be this assumption that the more health care you get, the better," said Dr. Deborah Grady, director of the University of California, San Francisco, Women's Health Clinical Research Center.

Grady co-wrote an editorial for the issue entitled "Less Is More: How Less Health Care Can Result in Better Health."

"Less Is More" will become a feature where the Archives of Internal Medicine will spotlight treatments that have gone beyond their original purpose and expanded to the point where the risks of the treatment outweigh benefits.

Treatments may come about to help a certain population, but when a medical treatment is overused in an otherwise healthy person, "There can only be harm," Grady said. "We'd really like to bring attention to this."

And Grady said that goes beyond doctors, to getting patients to question whether they need additional medical treatment.

Studies in the current issue look at potential risks of proton-pump inhibitors, which were originally designed for gastric reflux but now are used for conditions as mild as heartburn.

"They're given for upset stomach, stuff that will be gone tomorrow, stuff that could be avoided by adopting a diet that doesn't upset your stomach or give you heartburn," Grady said.

Dr. Nortin Hadler, a professor of medicine at the University of North Carolina who has written extensively on the overuse of medications and treatments, called the Archives' efforts a long-overdue step.

"There are a number of us who have been beating that drum for a while," he said.

He said the proton-pump inhibitors, or "little purple pills" highlighted in the current issue, were a prime example of overuse of medication without a clear need.

"When heartburn becomes a disease as opposed to one of life's predicaments is a very interesting discussion," Hadler said. "We can medical-ize heartburn so every time they get it, people run for a pill."

Using the pills, as the Archives issue shows, can bring risks that include osteoporosis and infection with C. difficile bacteria.

Those problems may be outweighed when the treatment is for a severe condition, but, Hadler said, when treatments are used for milder conditions, "There is no effectiveness, there is no benefit, there are only side effects."

Lessons in Communication

Proton-pump inhibitors will not be the first medical intervention to earn headlines as doctors recommend they be used less. And a very contentious recent change in guidelines may give some doctors pause in recommending less treatment.

In November 2009, the U.S. Preventive Services Task Force recommended that women without an increased risk of breast cancer who were between the ages of 40 and 50 no longer needed yearly screening for a mammogram.

The backlash that followed carried headlines.

"I think that the U.S. Preventive Services Task Force learned there is a certain science to communication just as there is a science to treatment," said Dr. Otis Brawley, chief medical officer for the American Cancer Society.

He said that while the guidelines were not that different from those of the American Cancer Society, the way they were communicated caused an outcry, in part because it led some to believe a lifesaving tool was being taken from them.

The problem, Brawley said, came from both sides. Physicians in favor of screening "seem to be complacent with the technologies we have now," without acknowledging the false positives they pick up, he said.

At the same time, he said defenders of the USPSTF's recommendations seemed to ignore the fact that some clinical trials indicated lifesaving benefits from breast cancer screening (a benefit not yet known in, for example, prostate cancer screening).

Grady acknowledged that a challenge for doctors will be communicating the need to cut back on treatments.

For many scans, she said, we don't know that they find cancers that will actually affect a person.

A common example, Grady said, is a patient who comes into the emergency room with a cold and where a (needless) chest x-ray appears to show a growth in the lung.

If there is no cancer, the patient is relieved, but if doctors had followed best practice, they wouldn't have gotten the x-ray.

"We know that doing a chest x-ray just for the hell of it not only isn't effective, but it identifies people with lung cancer that was never going to bother them," Grady said.

But as doctors are called upon to communicate better, patients may need to heed a similar message.

Hadler said spotlighting overused treatments and procedures will benefit involved patients.

"One can start to ask 'how certain are you that a particular intervention will actually benefit me?'" he said. "The patient has to demand information. They need to take responsibility for medical decision-making for them."