Medicine For People!

July 2015

X-RAY

Too Much Information

Mary

Mary came to me asking for a second opinion about mammograms. She was 32 years old and she'd already had to several needle biopsies as well as six lumps removed because of worrisome findings on a mammogram. They'd found nothing wrong, but she dreaded going for another mammogram. Mary had come to me in 1998. The evidence then showed the lifetime survival benefit of regular mammography to be something like 2 %. So I explained to her that only 2 % of women have their lives extended by getting mammograms. Further, her experience with mammograms so far had been disastrous. It was time to stop. Sure, if she felt a lump, get it checked out, but not before.

That was a decade ago, she took my advice, and she's been fine since. Meanwhile, the evidence in favor of screening mammograms has pretty much melted away entirely.[1]

The Incidentaloma

Calvin had a mysterious abdominal pain. Every condition I had considered seemed not to match his situation. The only clue was that he had run a high uric acid level for many years. This put him at risk for kidney stones, but he had no blood in the urine nor a family history of gout or kidney stones. Then one night, severe abdominal pain led him to the emergency department where a CT scan was done.

He came to me a couple days later, happy that he had no kidney stones but now concerned that the scan had found a lump in his liver. The medical term for this is an incidentaloma, meaning a tumor found incidentally while looking for something else.

Only rarely are these incidental findings evidence of something harmful. Every doctor has stories of a diagnostic treasure hunt gone wrong, such as the liver biopsy performed to make sure the lump is benign, only to set off bleeding requiring major surgery. The hunt for information (is this the rare lump that is harmful?) carries a risk of its own. Autopsies on older adults dying of other causes find about half of them to have benign lumps in the liver. Calvin was under 40 years old and had no cancer or liver disease. The lump showed no suspicious features. There was no reason for further investigation and none was performed. He suffered no problems as a result.

TMI

Frequently patients ask me to do an MRI of a painful joint. Usually I don't. If a surgeon doesn't need to see the MRI to make decisions about surgery, the study is worse than useless. It's too much information (TMI). What could be wrong with information, you ask? Well, I can tell you that if you do a hundred MRIs on people 50 or 60 years of age and older, you're going to see a lot of degenerative joint disease. Now, if you don't do the MRI and you can get them to go to physical therapy and other exercises at home, a huge percentage of these people are going to get well and have no further pain or at least have much less pain. But if you do the MRI, perhaps 5% of average people, as soon as they hear they have "degenerative joint disease," will hear nothing else. They'll go home with the impression that because their joints have degenerated, it means that they will always hurt, and so they will never enthusiastically participate in rehabilitation. They will be harmed just as much as a person who has a bad outcome from surgery.

2000 years ago a Greek physician named Hippocrates wrote out his major principle of medicine: "first, do no harm." When I started out in my practice, I thought this meant to be sure not to give the wrong medication or to mess up a surgical procedure. Now I know that even doing a diagnostic test can cause people harm. The mammogram and the unnecessary MRIs mentioned above are just the tip of the iceberg.

Cancer Care

You would think that as simple a thing as carefully watching for metastasis from colon or breast cancer would help people live longer. It doesn't, and there are even some indications that such careful screening means people don't live as long. Why? We are usually not able to do much about the metastases when we find them, so those with intensive surveillance just find out sooner and are scared to death. I am not kidding.

Several other studies (you can read about them in Gilbert Welch's Less Medicine, More Health[2]) have shown that efforts to give patients more information have not resulted in better health and may have led to poorer outcomes. Thus, information is like any other medical intervention. It must be used with care, because too much information can harm people.

What Einstein Said

The great physicist Albert Einstein[3] once addressed an auditorium full of physicians. He told them, "You are not scientists." I don't think he meant that as a criticism. The task of the scientist is to learn as much as possible about the world. The task of a physician is to improve health.

Keep Your Eye on the Goal

When people come into my examining room, the goal we both share is that when they go home they'll be able to live their lives with more comfort, more energy and happiness, and more ability to achieve the things they wish to achieve in life. Doing too many tests or doing the wrong test can distract us from that goal and may prevent an optimal outcome.  Our goal cannot be to have as much information as possible, but to have just enough of the right information.

Endnotes

[1] http://fivethirtyeight.com/features/are-mammograms-worth-it/

[2] Page 88ff

[3] The day before Einstein died of a ruptured aortic aneurysm, his physicians offered to try to repair it, which was by no means a certain thing at the time. Einstein accepted this information, then declined the surgery, saying "I want to go when I want. It is tasteless to prolong life artificially. I have done my share, it is time to go. I will do it elegantly." (https://en.wikipedia.org/wiki/Albert_Einstein#Death)

Edited by Jody Bower.

story: 

Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.