Going Overboard on Medical Tests

By Denise Grady

These days, a medical encounter would hardly feel complete to either doctor or patient without a battery of diagnostic tests. The days when doctors' decisions were guided solely by what they heard, saw, felt and thought have gone the way of the house call. With 1,380 tests available, from blood counts to CAT scans to electrocardiograms, some 19 billion were performed last year in the U.S. That means almost 80 tests for every man, woman and child, which surely makes Americans among the most analyzed people on the planet. In recent years, the amount of testing has steadily increased, by 10% to 20% annually. The cost in 1987: more than $100 billion, or 20% of the nation's bill for health care.

There is a growing sense that the money is ill spent. Critics charge that doctors, through greed, poor judgment, or fear of malpractice suits, are ordering billions of dollars' worth of needless tests. Patients are willing accomplices, ever ready to put their faith in what appears to be scientific evidence, despite estimates that 20% of all tests performed are unnecessary. Worse, owing to sloppy laboratory work or doctors' mistakes, the results are too often wrong or misinterpreted; thus they may actually harm patients by failing to detect serious diseases or by indicating illness when none exists.

Error rates vary from one procedure or laboratory to another, but Pap tests and screenings for cholesterol are among those that are most often incorrect. The Federal Government monitors only labs that serve Medicare patients or do interstate business. State laws have been described by one investigator as a hopeless patchwork. Some laboratories submit to proficiency reviews in order to be certified by private professional groups, but thousands of other privately run labs are unregulated.

Inspired in part by a series of Pulitzer prizewinning articles that appeared in the Wall Street Journal last year, Congress is investigating medical tests with an eye to improving federal control. Within a few months, lawmakers will consider legislation, recommended by the Centers for Disease Control, to set up uniform proficiency standards for laboratories. At Senate subcommittee hearings on the subject last month, Democratic Senator Carl Levin of Michigan declared, "Faulty lab procedures can have devastating consequences for the unsuspecting."

Tragedies have certainly occurred. Among the most notorious have been cases of women who, despite negative Pap smears, turned out to have cervical cancer. ( Some have died; others have been forced to have hysterectomies. Had the disease been caught early, minor surgery could have sufficed. Pap smears miss between 20% and 40% of cancerous and precancerous specimens. Most often, the blame is laid on harried technicians who, paid according to the number of samples they process, may scan more than 100 slides a day with few breaks in so-called Pap-mill laboratories.

Other tests are also being botched. A House subcommittee has reported that, in recent proficiency tests, one in ten hospital labs could not measure blood platelets accurately -- a relatively simple and frequent procedure used to help measure a patient's ability to form blood clots. The labs also missed 12% of salmonella infections; doctors' office labs were even worse, overlooking 18%. Because of technical errors, cholesterol readings can vary enough to cause confusion about whether treatment is needed. And it can be hard, if not downright impossible, for patients or even their doctors to tell when a lab is making mistakes.

Still other mishaps are due to physicians' ordering the wrong tests or misinterpreting the results. Kansas City Endocrinologist David Sneid says about once a month he is called upon to treat patients whose doctors have unwittingly prescribed dangerous overdoses of a thyroid medication because the wrong blood test was used to monitor the treatment. In at least one case, says Sneid, the high doses "may actually have shortened the patient's life substantially." Such errors are multiplied by a growing trend among doctors to order more and more tests. Various blood analyses, previously ordered one at a time, are now packaged in blocks of 20 or more. "When you run a lot of tests," says Dr. Michael Alderman, of New York City's Einstein College of Medicine, "the possibilities are higher that one or more will come out wrong."

And tests beget more tests: the doctor may want to repeat the first measurement, or order others, to find out whether something is really wrong. Says Dr. Eleanor Travers, director of pathology for the U.S. Veterans Administration: "The more experience a physician has, the fewer the tests that should be necessary." Even so, an estimated 40% of doctors practice "defensive medicine," ordering tests they know are unnecessary in case of a malpractice suit later.

More disturbing, some doctors may be ordering needless tests in order to turn a profit when they have their own equipment and perform tests in their | own offices. More than 190,000 doctors, according to a Senate subcommittee, are doing some in-office testing. Brochures from the manufacturers blatantly appeal to the pocketbook: "In-office testing that helps build a nestegg," reads one, illustrated with a picture of a goose sitting atop a golden egg. Says Uwe Reinhardt, a Princeton political economist who specializes in health care: "Doctors maintain that they are impervious to the profit motive in their medical practice, and I would like to believe that. But one must then wonder why these presumably sophisticated manufacturing companies choose to communicate with doctors primarily through the language and imagery of profits." Most likely to be tempted, he believes, are younger, technology- minded doctors with huge medical school debts to pay off. "They want theirs back," he says.

How can patients protect themselves? Experts offer the usual consumer advice: grill the doctor about each test, ask if the lab is accredited by the Government or a professional group, refuse procedures that seem unneeded and insist on a retest when in doubt. But few people, when ill, are up to bucking their physicians or shopping around for lab tests. Insurance companies have more power. Last year Blue Cross & Blue Shield created new guidelines for common diagnostic tests, which suggested that the plan might eventually refuse to pay for unneeded ones. The ultimate goal: to prevent useless tests from being ordered at all. It is a small, first step in the right direction.

With reporting by Mary Cronin/New York and Glenn Garelik/Washington