Is More Medical Testing Better?

“I think this patient needs a CT scan of her chest,” the consulting
physician said to me over the phone. “Her lungs sound bad, and given her
history, we need to make sure she isn’t developing pneumonia.”

The patient, though only thirty-five, had been through a lot during her
hospitalization. She came in a week prior with some shortness of breath, an
abnormally high heart rate (tachycardia) and chest pain. But her heart
checked out just fine. An EKG was normal and her troponin, a protein
that spills into the blood with damage to heart, was undetectable. Because
of her tachycardia and chest pain we tested her for a

pulmonary embolus
, or clot in the lungs, with a CT scan. It was positive. The potentially
deadly clot blocks off blood flow coming from the right side of the heart
into the lungs causing heart strain and disrupting oxygenation of blood and
the functioning of the heart.

We admitted the patient to the

intensive care unit

where she received IV medication to thin her blood. She recovered but
continued to experience residual chest pain that would clear in the months
ahead. As we prepared to discharge the patient, the consulting physician, a
cardiologist, told us he wanted her to get another CT scan of her chest.
She had not had a scan since the initial stages of her workup. What if she
developed pneumonia in the interim? Her white blood cell count, often a
crude marker of infection, was not elevated. She did not have fevers. When
asked, she felt well enough to go home and wanted to leave. Then again,
being in the hospital made her susceptible to infection. Moreover, on her
physical exam, we heard crackles in her lungs –
this sometimes indicates an intrapulmonary pathology. The cardiologist’s
concern gave us pause and we ordered the imaging study.

~

Doctors often feel uncomfortable with areas outside of our expertise. Consequently, we call other specialists to see the patient and give us advice. Moreover,
patients sometimes ask to see a specialist in the hospital: “Can you call
the neurologist to come see me?” or “We’d like you to call a cardiologist
to see our father while he’s here.” Because consultants share a different
knowledge base than the team primarily caring for the patient they may ask
for more tests to rule out other serious pathologies that the primary team
neglected to consider.

The patient’s repeat CT scan merely demonstrated small collapsed alveoli.
These terminal branches of the lungs often collapse when we draw shallow
breaths or lie flat for a long time, a typical finding in many hospitalized
patients. Given the benign nature of this finding, we discharged the
patient. Yet she had received an extraneous dose of radiation and her
hospital bill would be hundreds of dollars more. Did she absolutely need
this? This common story raises other questions, too. Do patients do better
with more specialists seeing them? Do patients do better with more testing?

In a 2012 post for the New York Times Well blog, Tara Parker-Pope

pointed out

that “overtreatment – too many scans, too many blood tests, too many
procedures – is costing the nation’s healthcare system at least $210
billion a year, according to the Institute of Medicine.” And the stories
she tells about astronomical hospital bills due to overtesting are
disturbing.

In
a 2015 article in the Journal of the American Medical Association, a group of researchers found mortality for high-risk
heart failure and cardiac arrest among patients was lower in teaching hospitals
during national cardiology meetings compared to the rest of the year – meaning that the absence of a large number of cardiologists, who were attending meetings, was correlated with lower mortality for these heart conditions in the hospital. In an editorial in the same issue, Dr.
Rita Redberg makes a disquieting suggestion: “How should we interpret these findings? One possibility is that more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” Is there too much being done, especially by experienced
physicians?

Dr. Ezekiel Emanuel, an oncologist and bioethicist, elaborated on these questions in a New York Times op-ed in 2015:

We – both physicians and patients – usually think more treatment means
better treatment. We often forget that every test and treatment can go
wrong, produce side effects or lead to additional interventions that
themselves can go wrong. We have learned this lesson with treatments like
antibiotics for simple medical problems from sore throats to ear
infections. Despite often repeating the mantra “First, do no harm,” doctors
have difficulty with doing less – even nothing. We find it hard to refrain
from trying another drug, blood test, imaging study or surgery.

When specialists like neurologists or cardiologists see a patient, they
approach the bedside from a unique perspective. The pathologies they know
and think about are very different from what family medicine or internal medicine doctors thinks of when they see a patient. Specialists, who often act as consultants, consider the diseases they are most worried about within their field. They’ve been asked to see the patient to
recommend workup for a disease potentially related to
their area of expertise. Their view, in other words, is necessarily myopic – if you give a carpenter a hammer, surely the carpenter will find a nail.
This does not always happen, but by nature there is a bias when a consultant
approaches a patient – and that bias is toward ordering another test,
toward doing something. Part of the art of medicine, especially as a specialist or consultant, is figuring out when the patient needs
something and when the best approach is to do nothing at all. Our patient
at the beginning of the story did not really need a repeat CT scan. To be
sure, the cardiologist didn’t recommend it simply to radiate the patient or
increase the hospital bill. But none of us wanted to miss something.

A conservative method of practice can come with experience, but as evident
from the JAMA study referenced above, that’s not necessarily the
whole story. Some of this, I think, requires thinking regularly about how well the
patient in front of the doctor is doing and how a test will change the
course of the patient’s treatment. “Will this change our management?” is a
question our attending physicians always ask us before we order a test. And it is a
question all doctors must ask themselves.

Managing Expectations

“Yes. But could I endure such a life for long?” the lady went on fervently, almost frantically. That’s the chief question — that’s my most agonizing
question. I shut my eyes and ask myself,
Would you persevere long on that path? And if the patient whose wounds you are washing did not meet you with
gratitude, but worried you with his whims, without valuing or remarking your charitable services, began abusing you and rudely commanding you, and complaining to
the superior authorities of you (which often happens when people are in great suffering) — what then?

Fyodor Dostoyevsky, The Brothers Karamazov

I have a collection of idyllic memories from my childhood summers, traveling with family to the sleepy New England town of Lenox, Massachussetts. There we
would go hiking, watch movies, attend concerts by the Boston Symphony Orchestra at their summer retreat in Tanglewood, and swim. And we never failed
to visit the Norman Rockwell Museum in Stockbridge. Rockwell was one of the most well-known American painters
of the twentieth century and some of his famous works appeared on the covers of the Saturday Evening Post. His humorous, sentimental, and occasionally somber paintings capture everyday American life during the early and mid-twentieth century, portraying families eating dinner, children arguing about a basketball game, and teenagers at a lunch counter.

Norman Rockwell, Doctor and Doll (1929)
Curtis Publishing

One painting in particular sticks out in my mind, Doctor and Doll, drawn for the Saturday Evening Post cover of March 9, 1929. A dapper physician in a suit and tie sits in a chair. A young girl in her winter clothes with a hat,
scarf, and mittens scowls at the doctor, reluctant to let him examine her. She’s upset, as so often children are, to be seeing a physician. She holds her
doll up to him as he gently pretends to listen to the doll’s heart with his stethoscope. He plays along with the young girl, earning her trust so that he
can, perhaps, listen to her own heart next. The doctor does not look down at a note or a chart while taking care of his patient. He’s not
rushing to leave. He merely attempts to establish trust and takes the time necessary to earn it. It is the paradigmatic image of what we want a doctor’s interaction
with a young patient to look like, an idealistic portrayal. And Rockwell realized that this was true of many of his paintings. He
once said: “The view of life I communicate in my pictures excludes the sordid and ugly. I paint life as I would like it to be.”

But hyperbole, though an artistic
strategy, is not always evident to children on family vacations. While the Rockwell painting does not
exactly illustrate my expectations of medicine, it does exemplify a certain naïveté with which I approached medical school. I knew I would work incredibly
hard and I also knew, after reading firsthand accounts from several physicians, that I would see horrible things. However, I retained some of that boyish
optimism about medicine and imagined that the majority of my interactions with patients would be as depicted in Rockwell’s painting.

Since then, however, much has changed. I was recently chased down the hall by a psychiatric patient who had a low sodium level (which can lead to seizures).
We needed to get a sample of his blood to recheck his electrolytes, but he refused and when I tried to explain to him why we needed to get labs, he jumped
out of bed and ran after me, saying: “I’m going to f***ing show you how I do things.” Another patient recently told me “I don’t need to f***ing be here” and ran out as I chased after him. I have been called an “idiot” and a “fraud.” I have also been screamed at, given the middle finger, and physically threatened. Yet another patient threatened to report me to the New York Times because his room
was too hot. I have tried convincing countless numbers of patients (sometimes successfully and sometimes not) to take life-saving medications. I
saw a patient fall out of her bed, micturate on the floor, and go into cardiac arrest. Another patient threatened to slap me after I ordered an
EKG to examine his arrhythmia more closely. There have been
times when I have had to choose between spending time writing notes and speaking with patients and their families — and have paid the price for choosing the former. I have performed CPR more times than I’d like to think about. And there is, I am certain, more to come.

None of this is evidence that I have come to dislike practicing medicine. I selectively edited out the brighter episodes to make a point:
medicine is a universe away from what most of us perceive it to be. It is far more dark, depressing, and quick-paced than anything I imagined. It is, in short, messy.
But I believe it has always been this way. Samuel Shem’s The House of God, published in 1978, is a satirical novel filled with familiar yet horrific stories and
bizarre interactions that characterize a physician’s first year of residency. (I’ll write about this book in another post.) That experience of some forty years ago is hauntingly similar to my own. The passage at the beginning of this post from The Brothers Karamazov, completed in 1880, resonates with me as well.

Residency has altered my expectations. Humans have always been sick and will probably always face sickness and death. And sickness and death are deeply unsettling experiences that sometimes prompt strange
and disturbing behaviors. They challenge our youthful notions of invincibility and immortality. They expose our weakness and decrepitude and force us to
confront an end that none of us can face with a straight spine. A hospital lays bare these notions — and the whole experience makes it difficult to be calm, reasonable, and
understanding. Who can be levelheaded in this perpetual twilight?

For that we must return to Rockwell’s comforting painting, a glorified image of what we want from medicine. If we look closer we may see the painting differently.
The doctor has made little progress with his patient. The girl has not removed her hat, scarf, or shoes. She has not yielded one bit. She merely lets her doll be the “patient.” And yet the doctor readies himself to do whatever it takes to help her. Almost imperceptibly smirking, he patiently listens to the doll’s
chest. He is not angry or frustrated but sympathetic. Perhaps we can face the daily frustrations of the hospital better with some of that Rockwellian spirit to strive for life as we would like it to be.

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in
trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes
on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also
confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I
mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever
discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to
it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is
why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will
“make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted
something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was
having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the
elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health”
in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my
question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an
answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a
technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there
will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the
purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her
golf swing, or a family physician might administer amphetamine injections to people who want to
feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed,
doctors daily witness death and terminal illness. If we know CPR,
do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the
prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy
are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines
breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely
solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine,
is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the
Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism … composed of parts. It is a structure and not a
heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that
make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is
not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and
buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts
and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This
demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children
who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis
to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human
being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not
involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic
surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought
to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for
patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes,
“large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine
and we would be remiss if we didn’t study this purpose carefully. Without a purpose,
medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.