While meeting with a patient for her annual check-up last week, Dr. Melvin Kirschner noticed some abnormal tissue in his examination. He informed the patient that he was ordering a test, but the patient, a breast cancer survivor, wanted more information. She wanted to know all of the illnesses she could have, and Kirschner explained a wide range of possibilities. Following the exposition, his patient suggested that he ought to run more tests. Dr. Kirschner, who has been a family physician in Van Nuys for 44 years, found himself in a position that his fellow physicians face every day. Patients, after reading about the newest innovations in medical technology, decide that they are better safe than sorry, and push medical providers into ordering every available test, doctors say. The problem, they claim, is that many tests are unnecessary, unreliable, expensive, redundant and even dangerous. Every physician faces the very real risk of lawsuits however, and they say that pressure sometimes lead to the ordering of too many tests in order to keep patients happy and stave off future litigation. Although he felt no particular medical or scientific drive to do so, Kirschner ordered three tests for his patient. Kirschner’s example is a mild example of a widespread problem. Since she had a past history of cancer, Kirschner said he expects the woman’s insurance company to pay for the tests. Not every patient is as easy to deal with. Many doctors feel that patients are becoming experts on their own health at a very real risk, causing them to ignore the advice of medical professionals while simultaneously expecting them to cure and even prevent all illnesses. “There is increasing pressure not only to be right 100 percent of the time but to predict the future 100 percent of the time,” said Dr. Jonathan Macy, an ophthalmologist practicing in West LA. Macy said that his patients routinely ask for tests that Macy considers to be unnecessary. “They may or may not be of any value, but they’re marketed like crazy long before the value is determined,” said Macy. Many new tests written about in national medical journals have been tested on a very small number of people, and show results that have not been duplicated by other physicians. Still, when the tests start making headlines, doctors find patients ready to bang down doors. Dr. Marc Graff, a psychiatrist working for Kaiser Permanente in Reseda, recalled that a report on a new test featured in the New England Journal of Medicine made headlines in Los Angeles. That day, a patient of Dr. Graff’s showed up at his office wanting him to order the test for her. “I explained to her that it was experimental, and had only been used on a few patients,” he said. Also, the test was only being conducted at a facility in Maryland on test subjects. His explanations fell upon deaf ears. “She decided I was not listening to her and stomped off,” said Graff. Popular tests Some tests become enormously popular despite no clear indication that they have a medical benefit. Full-body C.T. scans are currently in vogue. Patients assume they will discover early treatable diseases from them, but doctors say that’s hardly guaranteed. Dr. David Schechter, who practices sports medicine and family practice in Beverly Hills and Culver City, says patients are constantly asking for the full body scans. “People hear that every time Kobe Bryant twists his knee he’s getting an MRI,” said Schechter. “I can examine a patient and find an over 95 percent likelihood that it’s unnecessary, but if they’re willing to pay for it, it’s certainly their prerogative.” When patients do decide to pay for the tests themselves, they may end up causing more problems when they solve, though. The effect of radiation used in the full-body scans has yet to be evaluated, and some think that getting scans on a regular basis could be harmful. Additionally, patients may find something in a full-body scan, but it may turn out to be a small abnormality rather than a symptom of a serious medical condition, Schechter said. The result of such a find could result in an uneasy patient sending their doctor chasing after phantom diseases. Public opinion about some tests is so far from the truth that educating patients can take up a significant portion of a doctor’s time. Dr. Amy Rosenman, a gynecologist practicing since 1979 said patients come into her office constantly asking for a CA 125 test. The test looks for an antigen in the blood that is commonly found in people with ovarian cancer. Rosenman said that the test has been proven to be extremely unreliable, but the test is still widely discussed and promoted on the Internet and through e-mail, and it constantly draws the attention of self-diagnosticians. Even worse, Rosenman said, is the fact that the CA 125 test is mentioned in a brochure supplied by the state that doctors are required to give patients. “It’s behind the times and we are left to educate every patient on the pros and cons,” Rosenman said. “Ultimately I will play to their emotions and say ‘I have ovaries, and I wouldn’t get the test.'” ‘Defensive medicine’ Dealing with overzealous and uneducated patients has altered the way that some doctors practice. Kirschner says that doctors are forced to practice “defensive medicine” almost as a reflex. Kirschner said he documents every recommendation that he makes to each of his patients in case his judgment is ever called into question. “One of my colleagues said he writes in his charts ‘I advised him to do such and such, and warned that he could die if he didn’t,'” Kirschner said. Still, most physicians say that if they work hard enough to educate patients, trust between doctors and patients will prosper. Dr. Marcy Zwelling-Aamot, a doctor in Los Alamitos and immediate past president of the Los Angeles County Medical Association, said she runs into patients constantly who know very little about their own medical conditions. She said that last week, she talked to a new patient who had been living with diabetes for the last 20 years with only a minimal understanding of the disease process. Zwelling-Aamot said that while most doctors continue to make visits brief rather than educational, patients will continue to rely on their own research rather than their doctors’ opinions. Within trusting doctor-patient relationships, she said, patients are more likely to be understanding of their doctors’ fallibility. “Mistakes are going to happen, but most patients are incredibly forgiving,” she said.
Taking Preventive’ Medicine to Extremes