Vol. 156 October 15, 2016 Adding “DNT” to Your Medical Record Before “DNR”

 

Hub thumbnail 2015At our last weekly gathering of the “Over 70 Men’s Breakfast Club” we heard from one of us the following about visits to two of his physicians on the same day a week before:

Gastroenterologist: “Congratulations, your colonoscopy was entirely normal.”
Patient: “Great. When should I schedule the next one?”
Gastroenterologist: “Well ,, er..um .. you are over 75 you know. At your age it …er…um.. wouldn’t make any difference.”

The same day with his primary care physician:

Patient: “I think my urine stream is slowing a bit. How’s my prostate?”
PCP: “Your prostate exam is absolutely normal.”
Patient: “What about a PSA test?”
PCP: “ We don’t do those for men your age. It …er…um…wouldn’t make any difference in the long run. Oh, by the way, who’s your Health Care Proxy, the person who can make you DNR in case you can’t speak for yourself?”

Over our eggs and bacon (one member, our oldest, has oatmeal and berries instead) we reached the consensus that his medical record should be stamped with a “DNT: Do Not Test”.

Here are some of the “unnecessary” screening tests that he and others “of certain ages” should skip:

PSA: Rarely done under 50 yo. or over 70 yo. and now being questioned as of mixed benefit for any man. Screening does not reduce the very, very low death rate from prostate cancer and false positives are common. Further investigations of false positive results can cost at least $1,200 per patient, and treatment of truly positive cases can cause incontinence and/or impotence without any significant medical benefit.

Colonoscopy: rarely done under 50 yo. and never over 75 yo. as a screening test. Repeat colonoscopy after an initial normal one detects cancer of the colon no better than a periodic fecal occult blood (FOB) test on a stool sample done by your primary doctor.

X-ray, CT scan or MRI for low back pain without other symptoms: Back pain usually gets better in a month whether you have imaging done or not. Surgery is often done on image irregularities which have no causal relationship to the pain.

Pap smear: Every 3 years for ages 21 to 30. Every 5 years from 31 years to 65. None after 65 yo. “Abnormal” but non-cancerous cells can be detected by this test, but do not need treatment. Pap smears are recommended even if the woman receives the HPV vaccine (Gardasil) because the vaccine does not cover all viruses that cause cervical cancer.

Vitamin D: Vitamin D is the current “vitamin in vogue”. Speculations about relationships with heart and other diseases are riff, but the data is not that conclusive. Many people have low vitamin D levels (as currently defined) but very low levels associated with real illness are extremely rare. Oral vitamin D treatment has not been shown to reliably raise vitamin D levels. A 10 minute walk in the sun and a breakfast with orange juice and eggs supply more than enough vitamin D. (Note: The blood test itself is not expensive, but in 2011 Medicare paid $224 million for vitamin D screening on seniors.)

Testosterone level:  Despite the plethora (I am told) of late night TV ads selling gels, patches, and pills for low testosterone among middle age and older men, treatable “low testosterone” is rare.  Unless a man has one or two of 9 specific symptoms ( and erectile dysfunction (ED) is NOT one of them) a testosterone blood level screen is not recommended. Even if the level is low (under 10 nmol/L – I’m not sure what these units are either, except that they are very small ) a treatable diagnosis rests on the clinical history and exam, not the blood test.

Bone Density: Never under 50 and rarely over 70 in men without risk factors like fractures, heavy smoking or drinking, or very low Vit. D levels. Women could get one done at age 65, but  “treatment” of low bone density with costly medications (also advertised a lot on TV) has not been shown to have much benefit.

Annual EKG or stress test: Does not add any useful information for the asymptomatic person.

Whole Body Scans: Besides the cost and the large amount of radiation involved, these scans should be avoided because they do NOT find asymptomatic cancer. Less than 2% of the scans find a true mass and most of those are benign or inconsequential. In over 33% of scans “abnormal findings”, sometimes called “ditzels” by radiologists, lead to unnecessary and expensive further imaging tests that do not result in any benefit to the patient. (This test was previously heralded by this blog as a good Christmas present for an enemy)

References:

1. Choose Wisely is a list of unnecessary medical tests complied by the American Board of Internal Medicine from suggestions of numerous other specialty groups and published widely in Consumer Reports and other periodicals.

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