My father died the day after Christmas. I think he waited so he would not ruin Christmas for the rest of us. That would have been consistent with his considerate nature. Six months earlier, we were able to relocate him to the same city where both my sister and I live. He lived with her, and during that time, he received excellent care. His physicians and nurses understood his goals of care and what mattered to him most. They communicated with each other as well as with my father and members of our family. His care was both appropriate and coordinated to the very end.
This was in striking contrast to the disjointed care, with seemingly endless tests, his physicians had imposed on him in his home city. Tests were ordered for him that were dangerous and demonstrated that his physicians were not listening to him and not using basic diagnostic skills. Undoubtedly, several of these tests would have ended his life prematurely had I not stepped in.
When my father was 91 years old, he developed failure to thrive. It was painful to see him lose interest in food and activities that he formerly loved. His weight loss was not subtle and evaded the creative efforts of his family to restore his interest in eating. It was also quite apparent that he was depressed and in emotional despair. In response, his physicians ordered 2 sets of electromyographies, a computed tomographic scan with contrasts, an esophagogastroduodenoscopy, and colonoscopy. There was also an impressive list of laboratory tests, many of them duplications and all ordered by a “team” of physicians who neither spoke to one another nor demonstrated any interest in doing so.
My father was not asked about his dentition, family and home environment, diet, or his emotions. Where were the skills we were taught in medical school: the careful listening to a patient? After each physician’s visit, I would ask my father what questions were raised, what information did he share, and how did the physician respond? Each time he would describe little to no discussion; only more tests.
Not being in the same city at the time, these discussions with my dad would launch me into a series of telephone calls and e-mails with his physicians in an effort to coordinate his care and get to the bottom of the logic behind all the tests. The computed tomographic scan with contrast would most likely have threatened his already borderline renal function. The colonoscopy preparation in the presence of his dehydrated condition, along with the complicated management of his anticoagulation, presented another risky situation. These conversations with his physicians often left me shocked at their lack of concern about the risk of these tests and their total lack of understanding that my father did not want more tests.
Between them, my parents survived cancer, blindness, arthritis, near fatal arrhythmias, and several major surgical procedures. My mother is still alive and well into her nineties. They both had the good fortune of being able to discuss risks and benefits of the prescribed tests with me and were comfortable saying, “no thank you” to procedures that offered little value. But most patients are not able to make informed decisions. Most patients do not have a physician in the family to protect them from unnecessary intervention.
We know the reasons for overuse of medical treatments and tests are multifactorial. We also know that most of the time, the clinician has good intentions. But ordering dangerous tests for frail elderly patients who do not want them demonstrates lack of both knowledge and caring. The physician community can no longer ignore overuse. We need to engage in a frank discussion. We must increase awareness and find solutions. We also need to frame the problem of overuse in the context of a quality and patient safety concern.
Corresponding Author: Ana Pujols McKee, MD, The Joint Commission (firstname.lastname@example.org).
Published Online: December 23, 2013. doi:10.1001/jamainternmed.2013.13423.
Conflict of Interest Disclosures: None reported.