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Editorial JANUARY 2008

Between a Rock and a Hard Place – The Wedged Physician

Anita L. Nelson, MD; Zuhra Musherraf, DO

As advocates for their patients' well being, physicians today must routinely battle with third party payors to gain coverage for services needed by their patients. As business-people, physicians must not only maintain their patient base, but must also contain costs in managed care and capitated systems. As professionals, we must act on the basis of scientific evidence. In the face of all these potentially competing objectives, it does not help when commercial interests seek to increase their own profits by generating demand for products or services that offer no benefit to patients or actually can do them harm.

One classic example of this is the 47-year-old patient who comes to your office and complains of some vasomotor symptoms and delayed menses. She asks you to order those “hormone tests” she has heard so much about that will tell her if she is perimenopausal. She does not seem to understand that perimenopause is a clinical diagnosis. The laboratory tests she has been encouraged to ask you for are not only superfluous, but the test results can actually be misleading. Perimenopausal women are in a state of “hormonal chaos”; one day a perimenopausal woman can have hormonal profiles consistent with menopause and 2 weeks later she can ovulate.1 You know that if you order the tests she asks, you will be practicing bad medicine, but you worry that if you do not order those tests, you may lose her as a patient. It always seems as if there is someone down the street willing to provide these services. The extensive hormone tests ordered by the so-called “PMDD clinics” are an order of magnitude more useless, especially when the tests are performed without regard to the patient’s cycle day. Exactly what is a woman’s progesterone supposed to be on cycle day 8? And how does that relate to PMDD?

Cancer screening tests are another area ripe for conflict between what the evidence indicates is appropriate and what technology allows. Just because something can be done, does not mean it should be done. For years we have had to fight the pressure from certain groups to do transvaginal ultrasounds and serum CA-125 tests on all women over 40 to detect early ovarian cancer. The evidence is unequivocal that for the general low risk population, these tests are not only not indicated, but doing them can result in unnecessary surgeries for women who have asymptomatic benign abnormalities.2 Creasman and DiSaia estimated in 1991 that if every woman in the US over age 40 underwent transvaginal ultrasound and CA-125 testing, it would cost about $13 billion each year, and there is still no evidence that even one life would be saved.3

Similarly, women have not been very willing to forego annual Pap smear tests and, as a result, the new evidence-based guidelines have not been universally adopted. Many of our colleagues complain that it is faster to do an annual Pap smear test than it is to explain to the patient why she does not need it. Adding to the problem is that, as women have recently learned that some types of human papillomavirus (HPV) have oncognic potential, they want to know if they carry any of these viruses. While testing for high-risk HPV is an important adjunctive test in specific clinical situations, many women are asking to be tested for HPV just because they want to know. Pressure to do HPV testing is expected to increase in the near future as type-specific HPV testing becomes commercially available and advertised directly to women. It will take even more time to explain to the patient why this test is not necessary or appropriate.

Today more women are beginning to ask for MRIs to screen for breast cancer. MRI does have the ability to detect more breast cancers in women with dense breasts, but not only is the test almost 10 times more expensive than mammography, it has a much lower positive predictive value than mammography.4 Even in high-risk populations, the call back rate was twice as high as mammography. Women with false positive results will require stressful and unnecessary follow-up tests to rule out malignancy. MRIs are best reserved for women with lifetime risks of 20%-25%, such as those with BRCA or BRCA mutations.5 There may be a role for MRI in the evaluation of contralateral breasts in women with recently diagnosed breast cancer.6 However, as women hear from talk shows and other reliable sources that there is a “better” test, they will undoubtedly start to ask for it. They may even cross the line and ask us to come up with some reason that requires the MRI “so their insurance will pay for the test.”

Not that we want to be nihilists or to discourage innovation, but we are finding that the rush to introduce new technology beyond the areas in which evidence shows that it is beneficial is an increasingly large problem. ObGyns are painfully aware that once a test becomes standard of care, it is hard to abandon. We never want to say no to our patients or deny them access to anything that will improve their health. It is hard for patients to understand why every new test is not necessary and we really do not have enough time to explain why the test they want is not a good idea. At a time when clinicians do not have as much time as they need to screen women for all of the reproductive health issues they must cover in a visit, these diversions detract us from our responsibilities, create frustration in our patients, and drive a wedge of mistrust between the patient and her physician.

No one really can blame women for their enthusiasm for new tests, because they are surrounded by advertisements and anecdotal stories, all clearly urging their use. In this setting, we need our thought leaders and professional organizations to develop patient education materials in electronic and in print formats, which explain in clear terms why there are limited applications for new tests and what the legitimate uses of the tests are. These materials should not mention cost-effectiveness even once. Those discussions only reinforce the patient’s suspicions that we are denying her the test so that we can pocket the money. The needed patient information materials should describe in some detail the downside of being tested (a false positive result), what that would mean for her (anxiety, repeat testing, possibly unnecessary surgery), and the likelihood that she would receive such a test result. This type of information coming from a respected medical authority could really help the woman (and, hopefully, her friends) understand again that her physician is really on her side for health.

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Anita L. Nelson, MD, Board Member
Zuhra Musherraf, DO, Los Angeles, CA

References

1. Santoro N, Brown JR, Adel T, Skurnick JH. Characterization of reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab. 1996; 81(4):1495-14501.
2. U.S. Preventive Services Task Force. Screening for ovarian cancer: recommendation statement. Ann Fam Med. 2004;2(3):260-262.
3. Creasman WT, DiSaia PJ. Screening in ovarian cancer. Am J Obstet Gynecol. 1991;165(1):7-10.
4. Kriege M, Brekelmans CT, Boetes C, et al; Magnetic Resonance Imaging Screening Study Group. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med. 2004;351(5):427-437.
5. Saslow D, Boetes C, Burke W, et al; American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89.
6. Lehman CD, Gatsonis C, Kuhl CK, et al; ACRIN Trial 6667 Investigators Group. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007;356(13):1295-1303.