Wednesday, June 23, 2004

In his first post in the Paternalism in Medicine series Trent Mcbride kicked off a lively debate about how the classification of certain medications as "prescription only" was driving up the cost of medicines and medical care. Well, according to this recent entry on Reason Online the same argument may be applied to medical imaging tests:

Sometimes a little bit of information can be worse than no information at all. But is that really true when the information is about your own health? The Food and Drug Administration and the American Medical Association think it's dangerous and inconvenient for patients to look inside their own bodies on their own initiative and at their own expense.

CT (or CAT) scans and X-rays have become standard medical diagnostic tools. These non-invasive body scans are prescribed routinely by doctors to look inside a patient's body and discover what is causing symptoms from headaches to chest pains. This body scanning technology has become so well known, easily available, and inexpensive that some clinics are offering preemptive screening exams for people without any specific symptoms at all—and advertising directly to the consumer.

Companies like Heart Check America and LifeScore offer patients direct access to medical scanning procedures. They do not require a doctor's prescription, and usually do not provide detailed analysis or consultation about the results of the scan. The patient gets a copy of the scan results, which he can take to his own doctor if abnormalities are found. Patients are drawn to the clinics by the possibility of stopping a life-threatening illness before symptoms are even felt, and by the peace of mind that a scan with no abnormalities can bring.

The FDA and AMA are outraged by this. They argue that CT scans have not been proven to be effective as screening tests—that normal results don't equal perfect health and abnormal results can cause a lot of worry over something that turns out not to be serious. And they worry that people will use body scans as a substitute for regular medical care.

Americans are savvy enough to know that a high-tech scan is no substitute for the personal care of a family doctor. And people willing to spend hundreds of dollars of their own money to check their health from the inside out are not likely to skimp on a visit to the doctor that is paid for by insurance. Instead, these patients are not satisfied with the passive role that traditional medical practices has scripted for them. They want to take control of their health situation, and now technology and the free market are providing that opportunity.

Pregnant women want to peek under their skin for non-medical reasons, too. In recent years, "keepsake" ultrasound photo clinics such as Fetal Fotos have sprung up in shopping centers around the nation. These clinics can take 3D pictures and videos of babies-to-be that are much more viewer-friendly than the fuzzy 2D ultrasound pictures obstetricians are specially trained to analyze.

Prenatal ultrasound has been around for decades, and is safely used to check a baby's gender and spot possible birth defects. Better pictures mean higher exposure to ultrasound for a longer time than routine medical checkups, but even the FDA admits that there is no evidence that ultrasound can physically harm a fetus. Nonetheless, the medical nannies at FDA caution against the use of ultrasound for "medically unnecessary" purposes.

Once a medical device is approved, the FDA cannot regulate how doctors use the device, so access to body scans and prenatal ultrasound is not likely to be restricted outright. Yet the battle for consumer control of medical choices is raging on many grounds, from high-tech scans to contact lenses to contraception. With so much information readily available about the benefits and risks of medical procedures and devices, consumers are increasingly likely to have their own opinions about what is best for them. Doctors, and the government, need to adjust to that new reality.

The objections to body scans are multiple. They can generate "false negatives" which may lead to further tests which can be expensive, painful, and subject to complication. While CT scans are "non-invasive" they are not completely benign. There is the risk of radiation exposure and contrast reaction. Let me quote again a portion of the above:

....usually do not provide detailed analysis or consultation about the results of the scan. The patient gets a copy of the scan results, which he can take to his own doctor if abnormalities are found....

So you go and get a body scan...and something turns up. Instead of having the test performed in the context of a patient-physician relationship, where (hopefully) some discussion of potential results has occurred you are told, "Something is abnormal, go see your doctor". When you ask for some clarification you are told that Scans-R-Us does not provide "detailed analysis or consultation about the results". Good luck and good-bye. This can, unsurprisingly, cause anxiety. Similar to the anxiety felt by women when they come in with a radiologist-performed stereotactic breast biopsy which shows cancer. The extent of her counseling was "I was told to see you and bring this (path report) with me"

There can be questions about resource allocation. Some may ask, "How many children's vaccines (or mammogram sites, or health clinics)could be funded with that money?" My answer to that is if it is your own money, spend it as you please.

Sometimes you can head something off at the pass. How many adrenal cancers have been taken care of early because of the "incidentaloma" found on a CT after an car wreck. If aortic aneurysms could be found early then they could be repaired before complications arise. A few years ago there was the story of Don Sutton and Skip Caray, broadcasters for the Atlanta Braves. Caray underwent an angioplasty because a CT scan showed a severe coronary stenosis. What prompted him to do so? Don Sutton's body scan revealed a early-stage renal cancer that was resected for cure.

In reality, Sutton and Caray are the exceptions rather than the rule. But some lives may be saved. This is a issue that shows no signs of going away.

The American College of Radiology's position is here.
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