August 2002 • Volume 8 • Number 8 |
 Lenexa, Kan., resident Garry Porter, 52, ponders the results of his recent self-ordered full-body scan. |
You've heard the expression "the customer is always right." This notion is being tested in the world of health care, where consumers can now order a battery of health tests without a doctor's consultation.
The gain to patients is dubious. Cholesterol tests, computerized tomography scans, prostate-specific antigen tests and STD screens are all available -- at a price -- regardless of whether a person would benefit from such testing. One pharmacy chain even offers coupons in its store flyers for discounted osteoporosis screening.
Family physicians are taking notice.
"Sometimes knowing more is doing worse," said AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., who has taken the lead for the Academy in responding to inquiries about these tests. "What people really need is the ongoing relationship with a physician they trust who can help them put the pieces of the health care puzzle together."
Do the tests empower patients? Do they cause unnecessary concern? Do they falsely reassure patients? Do they drive up costs?
"Yes," said Roberts. "All of the above."
PLAYING ON FEARS
Roberts said he approves of the tests "to the extent that the tests prompt people to engage the system. But that's not how they are being used." The way he sees it, consumers are being given a false promise that submitting to testing somehow confers good health on the person tested.
Of course, some tests are useful, Roberts said.
"There are clearly some tests that have been helpful -- home glucose testing, for instance. That said, there are lots of instances where tests are being used inappropriately and are not proved to improve people's health," he said.
On a recent weekday, Alan Klaus, 53, arrived at his local pharmacy in Kansas City, Mo., to get his cholesterol screened. The convenience appealed to him. Within five minutes, he was seated with a tube in his arm to have blood drawn for a cholesterol test. "My wife is a nurse, and she told me I should do this," he said. At the suggestion of the pharmacy representative, Klaus also agreed to have a PSA test.
The problem, said Roberts, is that cholesterol levels are only a minute factor in assessing a person's risk for heart disease. "Total cholesterol is only one small piece of the puzzle. For a pharmacist to say, 'Oh, your cholesterol is normal,' may give the patient false reassurance," he said.
Then there's the PSA test that Klaus was offered. Roberts contends that the PSA test is one example of a test that has not been shown to improve people's health. Furthermore, suspicious findings may come back that warrant further, more invasive tests.
STRIKING A BALANCE
Other family physicians worry about the profit motive in making the tests available.
"Anytime you market directly to consumers -- whether diagnostic tests or medications -- you have to strike a balance between the positive values of giving patients more information about their health options and empowering them to request or even demand some health services that might benefit them, versus the negative values of driving up costs, misinforming the public so that private industry can make a profit, and so forth," said Howard Brody, M.D., Ph.D., professor of family practice and philosophy and former director of the Center for Ethics in the Humanities at Michigan State University, Lansing.
But Emily Essex, director of advertising and sales promotion for InterFit Health, a national health screening group based in Houston, said the direct testing is giving patients ownership of their health. InterFit is an outfit that provides the medical staff -- phlebotomists and medical assistants -- who administer screenings at chain stores.
Max Bouja, M.D., dean of the medical school at the University of Texas, Houston, is InterFit's corporate medical director. The organization has a medical advisory board, and there's a medical director in each state in which InterFit provides testing at corporations or in retail venues. Laurie Lee, president of InterFit, said, "We're not functioning in a vacuum. We're functioning under medical directors."
Essex said, "Our main objective is to help people take charge of their health. We give them the ability to take care of themselves in a more appropriate way and read their own results."
Physicians should not feel threatened by patients' direct access to the tests, she said. "Because we provide this service, they can have more time with their patients."
SEE YOUR DOCTOR?
Patients whose test results indicate intervention is imperative are contacted directly by an InterFit nurse or doctor and encouraged to see their own physician, said Essex. With slightly or significantly out-of-range results, patients' reports are stamped with an advisory note to consult their personal physician. However, there is no mechanism to ensure that patients follow through, she conceded.
What Theodore Ganiats, M.D., of La Jolla, Calif., finds worrisome is the accuracy of these tests. "All direct-to-consumer tests will have a certain number of false-positive results," said Ganiats, immediate past chair of the Commission on Clinical Policies and Research. "What are the patient and physician to do if the consumer test is positive? Retest in the doctor's office? What if the two results disagree? What is the appropriate management strategy?
"Unfortunately, this is rarely worked out in advance, so both the patient and physician move forward guessing what is the best management path."
But false-positive and false-negative results are only part of the problem, said Roberts. "The real danger is that these tests undermine and erode the doctor-patient relationship."
FULL-BODY SCANS
At the extreme end of the direct-to-consumer health test trend is the availability of body scans -- ranging from scans of specific organ systems to full-body scans.
Scare tactics abound. The brochure of one imaging center warned, "Heart attacks happen every day, even in apparently healthy people," and went on to list those who were at risk: men over age 35, women over age 40. A fairly broad range.
Roberts took issue with a June 24 Wall Street Journal article titled "Don't Let Your Doctor Keep You From Getting a Body Scan," in which the writer asserted, "the medical establishment has a vested interest in keeping patients out of scanning centers."
"That's laughable," said Roberts. "These tests generate more visits to the doctor.
"If you're doing the tests to avoid the doctor, you're going to need to see the doctor (to confirm the results) eventually anyway. Either me or the undertaker."
FP Report is published by the
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Copyright © 2002 by
American Academy of Family Physicians.