How a clinician’s desire to be thorough can cause a harmful spiral of unnecessary care
Dr. Meredith Niess saw her patient was scared. He’d come to the Veterans Affairs clinic in Denver with a painful hernia near his stomach. Niess, a primary care resident at the time, knew he needed surgery right away. But another doctor had ordered a chest X-ray instead.
The test results revealed a mass in the man’s lung.
“This guy is sweating in his seat [and] he’s not thinking about his hernia,” Niess said. “He’s thinking he’s got cancer.”
It was 2012, and Niess was upset. Though ordering a chest X-ray in a case like this was considered routine medical practice, Niess understood something her patient didn’t. Decades of evidence showed the chest X-ray was unnecessary, and the “mass” was probably a shadow or a cluster of blood vessels. These non-finding findings are so common doctors have dubbed them “incidentalomas.”
Niess also knew the initial X-ray would trigger more tests and delay the man’s surgery further.
In fact, a follow-up CT scan showed a clean lung, but picked up a suspicious “something” on the patient’s adrenal gland.
“My heart just sank,” Niess said. “This doesn’t feel like medicine.”
A second CT scan finally cleared her patient for surgery — six months after he’d come for help.
Niess wrote about the case in JAMA Internal Medicine as an example of what researchers call a “cascade of care” — a seemingly unstoppable series of medical tests or procedures.
Cascades can begin when a test done for a good reason finds something unexpected. After all, good medicine often requires some sleuthing.
The most troubling cascades, though, start like Niess’s patient’s, with an unnecessary test — what Ishani Ganguli, an assistant professor of medicine at Harvard and a primary care physician, and other researchers call “low-value services” or “low-value care.”
“A low-value service is a service for which there is little to no benefit in that clinical scenario and potential for harm,” Ganguli said.
Over the past 30 years, doctors and researchers like Ganguli have flagged more than 600 procedures, treatments and services that are unlikely to help patients: tests like MRIs done early for uncomplicated low back pain, prostate cancer screenings for men over 80 and routine Vitamin D tests.
Research suggests low-value care is costly, with one study estimating the U.S. health care system spends $75 to $100 billion annually on these services. Ganguli published a paper in 2019 that found the federal government spent $35 million a year specifically on care after doctors performed electrocardiograms (EKGs) before cataract surgery, an example of low-value care.
“Medicare was spending 10 times the amount on the cascades following those EKGs as they were for the EKGs themselves. That’s just one example of one service,” Ganguli said.
Cascades of care are common. A survey Ganguli conducted found 99 percent of doctors reported experiencing one after an incidental finding. Nearly 9 of 10 physicians said they’d seen a cascade harm a patient, physically or financially.
Yet in that same survey, Ganguli reported 41 percent of doctors said they continued with a cascade even though they believed the next test was not important for medical reasons.
“It’s really driven by the desire to avoid even the slightest risk of missing something potentially life threatening,” Ganguli said.
Low-value care critics say there’s a mindset that comes from medical training that seeks all the answers, and from compassion for patients, some of whom may have asked for the test.
As health care prices rise, efforts to root out low-value care keep emerging. In 2012, the American Board of Internal Medicine Foundation began urging doctors to reduce low-value care through a communication campaign called Choosing Wisely.
Over that time, about a dozen companies have developed software that health systems can embed in their electronic health records to warn doctors.