June 23rd, 2014
Unethical Health Screening: When Unnecessary Tests Do More Harm Than Good
The policy group Public Citizen is urging 20 hospitals in eight states to sever their relationships with HealthFair Health Screening because they believe the company’s heavily promoted, community-wide cardiovascular health screening programs are unethical and are more likely to do harm than good. ACC president Patrick O’Gara released a statement saying that, “The questions raised about screening have some merit.” CardioExchange asked Ethan Weiss, an Associate Professor at the UCSF School of Medicine, to share his thoughts on this issue. Further details are included in CardioExchange’s news coverage.
Conceptually, people (including many doctors) believe that we should do everything we can to discover occult disease like heart disease. The assumption is that if we look hard enough, we can find disease and intervene to change the outcome in a positive way. People may ask, “What’s the harm?” However, for cardiology at least, there is no evidence to support this assumption outside of screening for hypertension, lipid abnormalities, and diabetes. This situation is worsened when options such as executive physicals are offered, which harden the perception that there must be some health benefit, but you just need money to access it. Again, sadly, this is not supported by evidence.
There can be serious consequences to false-positive results. Usually the harm is limited to unnecessary anxiety caused by false-positive tests, but there are also costs (many of these tests are not reimbursed) and the rare cases where false positives result in more tests that lead to complications and very serious medical consequences.
I once had a symptomatic patient with well-managed risk factors who insisted on having a nuclear stress test annually. It had been something started by a colleague of mine who had seen him before me — a very senior and respected doctor — and it was hard for me as a young doctor to overcome the perception that I did not know what I was talking about.
I kept doing the stress tests for a few years, but all the while I tried to convince him it was a mistake. I finally resorted to telling him that I was concerned about all the radiation he was getting. He continued to insist on the tests because he believed (firmly) that this was helping him and could not harm him.
One summer, I got an urgent call from him from the U.S./Canada border where he was being detained — he had set off the Geiger counter crossing the border a few days after his stress test. He was shaken. I reassured him and convinced the border patrol that he was not a terrorist. The next time he came to see me, he agreed to stop having stress tests and has not had one since.
I do believe that we can and will eventually improve our prediction tools. Right now blood pressure, lipids, and diabetes are the only validated — and thus, recommended — things to screen. This does not mean that we shouldn’t talk about other factors such as weight, body composition, nutrition, and exercise with our patients. The truth is that the evidence base for these factors is pretty flimsy too, but we make the assumption that it can’t hurt, and I try to inform patients where we have strong evidence and where we do not.
The bottom line for me is to be honest with patients about what prediction and prevention tools we have and what the evidence base is for each of them. Going forward, we need to work on more robust and careful studies from which we can learn how to better identify at-risk individuals and also validate whether the new tools do what they should. Finally, we should work to show that the information we learn from these tools can help improve clinical outcomes.