Is that X-ray necessary or ‘medical gluttony’

The American College of Physicians (ACP), the largest U.S. medical specialty group, is rolling out guidelines to help doctors better identify when patients should screen for specific diseases and when they can be spared the cost, and potentially invasive procedures that follow. Many individual U.S. medical centers have launched their own efforts to build a protocol of patient care in fields such as diabetes or obstetrics, but the ACP effort has the potential to influence doctors nationally. ACP members include more than 132,000 physicians, mainly focused on internal medicine. "Excessive testing costs $200 billion to $250 billion (per year)," Dr. Steven Weinberger, CEO of ACP said in an interview from his office in Philadelphia. "There's an overuse of imaging studies, CT scans for lung disease, overuse of routine electrocardiograms and other cardiac tests such as stress testing." In an article published last month in the Annals of Internal Medicine, the ACP cited 37 clinical situations where screening did not promote health and might actually hurt patients. They included performing coronary angiography - a procedure that uses a special contrast agent and X-rays to see inside the heart's arteries - in patients with chronic, stable chest pain that is being controlled by drugs or who lack specific high-risk criteria on exercise testing. "It's medical gluttony," said Dr. Otis Brawley, chief medical officer of the American Cancer Society. "The ironic thing is that people are talking about rationing. We have got to think about the rational use of medicine in order to avoid rationing medicine," he said. For Weinberger, establishing guidelines on when to perform a range of diagnostic tests in order to cut waste out of the healthcare system is one of his top priorities at ACP. He should enjoy broad-based support, as U.S. healthcare costs reached $2.6 trillion in 2010, contributing to a spiraling national deficit. That's $8,086 per person, or 17.6 percent of the nation's gross domestic product, government figures show. Advertise | AdChoices Yet there certainly will be protests from some doctors who decry guidelines as undermining their judgment and the art of practicing medicine. Guidelines may also cut into their income. President Barack Obama's health law from 2010 recognizes the growing burden of costs, but its main goal was to extend healthcare coverage to millions more Americans. It deals indirectly with ways to curb expenses. The Obama administration's proposed budget for the coming year seeks to wrest more than $360 billion in health savings in the next decade by curbing payments to doctors, among other measures. Health economists and other policy advisers question whether doctors can be trusted to make the right calls. A study published in the October 2011 issue of the British Medical Journal showed that almost half of doctors involved in setting clinical guidelines in the United States and Canada for diabetes and cholesterol between 2000 and 2010 had conflicts of interest. "I don't trust professional societies to do it because that's how they make money - by doing tests and procedures," said MIT healthcare economist Dr. Jonathan Gruber. He cites estimates that about $800 billion - or nearly one-third of all healthcare spending - is wasted in unnecessary diagnostic tests, procedures and extra days in the hospital. Treatment guidelines will help curb overuse, but Gruber and others would prefer the government set them. Back problems The ACP last year published guidelines on using imaging studies to evaluate lower back pain, a common ailment where expensive diagnostic evaluation does not always help and sometimes hurts patients. Medicare data show that doctors often order MRI scans for patients with lower back pain who have not tried less invasive, less expensive treatments such as physical therapy. An MRI frequently leads to surgery, data show. One study by the National Institutes of Health that used data from the government's Medicare health plan for the elderly concluded doctors who prescribe MRI scans, which can cost $3,000, tend to follow up with even more expensive surgery. Dr. Daniel Resnick, a neurosurgeon who specializes in spine surgery, has been involved for years in establishing guidelines with the North American Spine Society, which represents 6,500 physicians. He said some fellow surgeons "got very angry" when his group rolled out guidelines. Advertise | AdChoices For years, spine surgeons treated certain types of back pain by fusing the front and the back of two disks, which for billing purposes were two separate procedures, he said. Today, guidelines recommend fusing either the front or the back of the disks, not both. "It's like wearing a belt and suspenders. There was a 'more is better' type of thinking. But we found evidence that doing more was worse than doing less," he said. "There was pushback. Some felt guidelines interfered with their decision-making. That they were promoting cookbook medicine." Resnick said he respects the ACP effort and believes it is the responsibility of medical societies to develop guidelines.