In my last post, I fleshed out some of the logical arguments for why overtesting (the practice of ordering lots of tests, “just to check”) can sometimes backfire on patients and lead to worse outcomes. Today I’m going to provide brief vignettes of two actual patients I cared for during my residency training to better illustrate the point.
The Stress Test Gone Wrong
Bob was a healthy man in his mid 60s who was enjoying his retirement when a close friend of his unexpectedly died of a heart attack. Alarmed that the same might happen to him, Bob made an appointment with his doctor and requested that he have a stress test to check his heart out. Though all professional organizations have now weighed in against the practice of the “preventative” stress test in patients without any cardiac symptoms (because time and again studies have failed to show that they save any lives, and because of stories like the one that is about to follow), at the time this was a common practice, and so a stress test was scheduled.
Bob’s stress test showed an area of possible concern, so he was referred to a cardiologist, who scheduled him for a catheterization. This is a much more definitive test to look for coronary artery disease, in which a catheter is threaded through an artery and up into the heart, and then dye is injected in order to visualize the coronary arteries and see if any blockages are present. Fortunately for Bob, his coronary arteries turned out to be free of any important blockages – the area of concern on the stress test had been a “false positive,” which is a surprisingly common outcome. Unfortunately for Bob, during the procedure he suffered a rare and devastating complication: a plaque in one of his arteries (that was small and would have never caused him any problems) broke off and travelled to his kidneys, choking off their blood supply. As a result, he spent the rest of his life on dialysis and died a few years later due to complications from his kidney problems.
A Lethal Case of Non-Lethal Prostate Cancer
Joe was in his late fifties when a PSA (a blood test to check for prostate cancer) was found to be elevated during a routine exam. He was referred to a urologist who performed a biopsy which found a small spot of low-grade cancer on his prostate. It has become increasingly clear in recent years that tumors like this are very common and often grow extremely slowly, such that they may take many decades before they start to cause any problems and therefore don’t always need to be treated. But at the time of this story, it was the standard of care to always remove prostate cancer, and this is what was done. After reviewing the options, Joe elected to have a prostatectomy – an operation in which his prostate was surgically removed.
Unfortunately, even fairly routine surgery can sometimes go wrong. In Joe’s case, he developed a bloodstream infection after the surgery. He spent several weeks in the hospital getting IV antibiotics. The infection in his bloodstream allowed bacteria to get into his knee, and he developed a severe knee infection, which ultimately required him to get his knee replaced.
I met Joe about ten years after all of this occurred, when he was hospitalized again with what started out as a simple urinary tract infection. Unfortunately, it didn’t stay contained, and again he developed a blood stream infection. Bacteria love prosthetic devices, and once the infection spread to his blood stream, it was only a matter of time before the artificial knee became infected. There followed a very long hospital stay, involving multiple knee surgeries, weeks of IV antibiotics, and stays in the intensive care unit. Despite our best efforts, Joe never made it out of the hospital. His death certificate listed the cause of his demise as complications from sepsis (a severe, systemwide, infection), but Joe’s death actually began years earlier when his PSA was found to be elevated.
If the above stories seem frightening, I want to remind my readers that these are extreme examples. Most medical procedures are safe and don’t lead to really bad outcomes like these. The point is not that we shouldn’t be doing cardiac catheterizations or treating prostate cancer – there are indeed many instances in which these procedures are life saving. It’s that ALL decisions in medicine involve weighing the pros and cons of taking a particular path. The pros (“maybe we’ll find an early prostate cancer and my life will be saved”; “I’ll get a clean bill of cardiac health and sleep better”) are readily apparent to patients, whereas the downsides are often more hidden.
We’ve all heard about that person who got lucky, was found to have disease x at an early stage, and is doing great as a result. The story about the guy who died as a result of a long chain of events that started when he got treated for a cancer that might never have killed him doesn’t catch our imagination in the same way. But it should serve to remind us that things are rarely as clear-cut as we’d like them to be in medicine.
