How Much Healthcare Do You Need?

Steve Sternberg and Avery Comarow

When you need the best care medicine has to offer, chances are you can find someone with the required skills in the United States. Whether it involves repairing a sick heart or blasting a cancerous clump of cells deep within the brain with a precisely targeted beam of radiation, advanced care is so widely available that America's health system long claimed bragging rights for providing the best care on Earth.

Then came a scathing report, now 13 years old, from the Institute of Medicine, a quasi-government think-tank known for tackling some of the toughest issues in healthcare. It charged that errors and unsafe practices in U.S. hospitals may kill nearly 50,000 patients a year, possibly even twice that number. A flurry of studies released since then show that the hazards in U.S. healthcare persist today--nasty bugs passed on to patients in hospitals and clinics, unneeded and risky tests and procedures, medications that hurt more than help, treatment guidelines that are overlooked or ignored, doctors who base treatment decisions on instinct rather than evidence, computerized health information technology that should make care safer and more efficient but too often does the opposite--and the list is still growing.

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The question, then, is: How can you take advantage of the strengths of the U.S. healthcare system and not be harmed by its weaknesses? The answer, in six words: Get only the healthcare you need.

The less you put yourself at the mercy of doctors and hospitals, the less likely you will be harmed. That means staying healthy. It means getting the right kind and right amount of preventive care, not too much and not too little. It means--and this isn't easy--not overreacting to information that sounds alarming. It also means getting a second opinion when you need one, preferably from a doctor who can be objective and doesn't have a stake in the outcome of your case.

"Be skeptical, ask questions, get information from different sources. Be more assertive and inquisitive," says David Goodman, a principal investigator at the Dartmouth Atlas of Health Care, a research project that has shown, among other things, that patients don't necessarily fare better in places where doctors and hospitals are more aggressive, and that far too often they do much worse.

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What does the right amount of preventive care mean? That depends on the state of a person's health, along with age, sex, and family history. Not everyone needs an annual physical exam, as long as he or she is healthy and without a family history of premature disease. "One basic principle," Goodman says, "is that if you're living well and feeling healthy, don't go looking for trouble." Unless you're overweight, you should get your blood pressure checked every two years after the age of 18, and more often once you turn 40. Most women don't need annual Pap smears. The U.S. Preventive Services Task Force (USPTF) says it's okay to hold off for up to three years. Keeping vaccinations current is a valuable way to stave off a list of preventable illnesses, from flu to cervical cancer (through human papilloma virus vaccine). Flu and pneumonia shots are especially important for people 65 and older, both to avoid the diseases and their potentially dangerous complications. Take your doctor seriously when she talks about good and bad fats in the diet and the value of dropping even a few pounds. Colonoscopy, unpleasant as it is, can be a life-saver. It's recommended at least once every five years for people 50 and older, because colonoscopy reduces the risk of dying from colon cancer by as much as 77 percent. Each year, a million people are diagnosed with colon cancer worldwide, and 500,000 of them die.

Too much of the wrong kind of preventive care can actually get you in trouble. Examples abound in a system that punishes doctors for omitting tests, rewards them for ordering unnecessary ones, and creates dubious borderline conditions such as osteopenia--a step short of osteoporosis--that too often lead to treatment with expensive drugs. And while the test itself may not seem so bad, especially if it's an imaging test that isn't invasive, the consequences of an unnecessary test can be profound, even life threatening. Steven Nissen, chief of cardiology at the Cleveland Clinic, tells of one such case, involving a 52-year-old nurse who agreed to a routine imaging test as added reassurance that her heart was healthy. Tests, for cholesterol, artery inflammation, and rhythm disturbances were normal. But her doctor suggested she undergo an extra test, called catheterization, which would allow doctors to flood her coronary arteries with a dye that reveals blockages. The tube delivering the dye tore one of the heart's main arteries, causing a massive heart attack. A bypass operation to repair the damage ultimately failed. The nurse ended up needing a heart transplant. "I have five more cases like it," Nissen says.

Doctors have become so concerned about excessive testing--especially tests involving radiation-emitting CT scans--that nine medical specialty groups, including the American Board of Internal Medicine, the American College of Radiology, and the American College of Cardiology, have joined forces to try to curb it. As part of an effort called "Choosing Wisely," each one produced a list (available at www.choosingwisely.org) of "Five Things Physicians and Patients Should Question." The lists includes such "Don'ts" as "don't do imaging for uncomplicated headache," and cautions doctors to try to dramatically reduce the number of CT scans they perform. Few experts think it's a good idea to undergo full-body CT scans to look for potentially cancerous spots in the lungs or for calcium build-up in the coronary arteries of the heart. "Thirty percent to 60 percent of CT scans are wrong, incomplete, or inappropriate," says radiologist and patient safety expert Chuck Denham of the Texas Medical Institute of Technology.

CT scans, even when appropriate, could potentially have a major impact on cancer rates nationwide. "We're now over 70 million CT scans being prescribed a year," says physicist Owen Hoffman, a radiation risk expert at a consulting firm called Senes Oak Ridge. Hoffman has estimated that, over time, these scans will actually cause 15,000 to 45,000 cancers in unwitting patients years after they were performed. Worse, Hoffman says, many of the scans could, and should, have been avoided.

CT scans aren't the only tests that raise concerns. The USPSTF task force has recommended against more than two dozen tests, grading them "D" for "Don't do it. There's zero net benefit or harm," says task force chairwoman Virginia Moyer, a pediatrician at Baylor College of Medicine in Houston.

One notable example is PSA testing for prostate cancer. One or two high PSA readings prompts many physicians to recommend a biopsy, a test to detect cancer cells that is uncomfortable, has risks of its own, and doesn't appear to significantly reduce prostate cancer deaths. Any benefit, the task force concluded, is outweighed by the risk that an incorrect diagnosis or unneeded procedure will lead to death or complications. About a third of men treated for prostate cancer end up with urinary incontinence, impotence, or both. About 1 in every 200 dies within 30 days from complications of surgery.

Another controversial example is screening younger women for breast cancer with mammography, which has many of the same drawbacks. In 2009, the government task force reversed long-accepted recommendations for screening women in their 40s, arguing that the benefits were outweighed by the risks of false diagnoses, biopsies, and unnecessary treatment. The task force now recommends screening every two years for women between the ages of 50 and 74.

It's also wise to be wary when your doctor recommends that you undergo surgery or some other procedure. Medical journals are littered with studies of procedures--some of them involving major surgery--that were once thought to be beneficial but bring no benefit and may cause harm. One glaring example is surgery for osteoarthritis of the knee, so popular in the 1990s that more than 650,000 procedures were performed per year without scientific evidence of any benefit. Numerous studies have since documented that patients were subjected to the pain and risks for nothing.

The list goes on. Renal artery stenting, a procedure designed to relieve high blood pressure by propping open the kidney's main artery with a spring-like device called a stent, has also been shown to provide little benefit and cause harm. Surgery for low back pain and tubes through a child's eardrum to relieve middle-ear infections.

One of the biggest controversies now unfolding in medicine centers on angioplasty and stenting, an alternative to coronary artery bypass surgery performed in more than 500,000 people a year. Mounting evidence suggests that, for many patients--other than those having heart attacks-- optimum drug therapy offers the same benefits with less risk. "Honestly, I believe that most doctors think that doing something is better than doing nothing," says Deborah Korenstein, an internist at Mount Sinai Medical Center in New York, who has studied inappropriate care. "Just because you can do something doesn't mean you should."

A principle worth committing to memory: The body takes care of itself. It can fend off colds and most infections on its own, without a boost from antibiotics and other medicines. Overreliance on drugs to kill bugs just beefs up the bugs, and study after study has concluded that antibiotics do little or nothing to treat colds, flu, sinus infections, ear infections, and most other routine conditions.

Cardiologist Rita Redberg, editor of the Archives of Internal Medicine, and Deborah Grady, her colleague at UCSF Medical Center in San Francisco, grew so concerned about patients undergoing questionable procedures that they launched a series in the journal titled "Less is More" to highlight research on unnecessary, inappropriate, and inadequately tested medical care.

"Before you agree to any procedure, ask a few questions," Redberg says. "'What are the benefits to me?' They can be very different for different people, depending on age, sex, and health history. 'What are the risks? Are there alternatives?'"

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