From Chapter 1: Do I really need that test?

X-rays, blood tests and high-tech scans can be life-saving. Medical tests are extremely valuable tools for diagnosing diseases, and then guiding decisions about what treatments might help. Testing of patients is becoming more and more common in doctors’ offices, hospitals, dentists’ rooms and other places where health services are delivered. The problem is that many of these tests are unnecessary.

An unnecessary test is not just a waste of your time and money: it can also be a threat to your health. Tests often appear to be simple and harmless, but this is rarely the case, as we will see from the three common examples discussed in this chapter.

Tests themselves can have serious side effects and sometimes even cause deadly disease. In some cases, having one test can lead you to a whole lot more tests and treatments that may in the end do you more harm than good. And, finally, having a test can be the first step towards making an otherwise healthy person feel as if they’re sick.

‘Do I really need that test?’ is a question that should be asked much more often, even when the test seems quick and painless.

One morning, a couple of years ago, Steven Birnbaum received one of those phone calls that parents fear most. His 23-year-old daughter Molly had been hit by a car while jogging and rushed to a nearby hospital. When Steven arrived at intensive care, his daughter was conscious but had serious head injuries. Thanks to the wonders of modern testing technology, the doctors had worked out that Molly’s main injuries were a fractured skull and severe concussion, but she was likely to make a full recovery. They knew this because Molly had undergone a sophisticated type of X-ray known as a computerised tomography, or CT scan. As she lay on an examination table which slowly slid her body into the big CT machine, multiple X-rays were taken, giving doctors a clear view of the inside of her head.

Molly’s dad, Steven Birnbaum, was able to make sense of the results of her CT scans and confirm that the treating doctors had got her diagnosis right. That’s because Steven himself was a radiologist, a specialist doctor who works with CT scans and other tests like X-rays every day.

As radiologists like Steven know all too well, modern tests regularly save lives. Blood tests detect deadly viruses like HIV/AIDS, X-rays reveal broken bones and ultrasounds can show up suspect internal lumps. Old-fashioned methods of diagnosing illness, like doctors taking a detailed history from the patient, remain as valuable as ever, yet few people would argue with the notion that sophisticated modern tests have helped many patients. And apart from helping find disease, having a medical test is also often a way of reassuring us that we are free of illness, and nothing is wrong. A normal test result can provide great relief.

The problem, of course, is too much of a good thing. In recent decades the use of tests in medicine has skyrocketed. In 1980 in the United States there were 3 million CT scans conducted. Now there are more than 60 million every year. That’s a twenty-fold increase. In Australia there has been similar rapid growth in the use of tests, which has caused serious financial headaches for those running the national health system, Medicare. The massive increases have been driven by many factors. Some doctors fear being sued, so they order tests to cover themselves rather than believing they are really necessary for their patient’s welfare. Sometimes patients ask for a test they don’t really need, without understanding the full consequences. And very importantly, many companies and individuals profit handsomely from the sale and use of tests.

More and more people around the world are becoming concerned about the overuse of tests. Increasingly, they are saying ‘enough is enough’. Dr Steven Birnbaum is one of them.

Back in intensive care, on the morning of Molly’s second day in hospital, Steven was still at his daughter’s bedside. On the first day the treating doctors had ordered several scans, all of which Steven thought were appropriate and necessary to make a quick diagnosis of what was wrong. But by the second day, he was becoming concerned. After Molly’s doctors had ordered three more CT scans, her father decided ‘no more’. He felt the tests being ordered were unwarranted. Like any type of X-ray, CT scans expose the body to radiation, and Steven feared that his daughter was being exposed unnecessarily to potentially dangerous levels of radiation.

As a radiologist himself, working in the United States, Steven Birnbaum was becoming more and more worried by the number of scans being performed at the hospitals where he worked. He feared that too many people were being exposed to too much radiation, and he was horrified that it was happening to his own daughter. He asked one of the people in charge of her care whether they had given any thought to what radiation levels they were exposing patients to in their hospital. They hadn’t. Steven was incensed. Like many others around the world, he is now working to make us all more aware of the dangers of these seemingly innocent scans.

Despite the enormous increase in the numbers of tests being performed in recent years, there is no good evidence that that increase has led to a similar increase in our health as a population. Major studies in the United States, where unwanted testing is the most out of control, show that in some parts of the country, three times more tests are given per capita than elsewhere. This has not meant that people from highly tested areas have better health. The concern is that an awful lot of money is being wasted, and an awful lot of people are having tests they do not need. It is now time to start routinely asking your doctor, dentist, acupuncturist or physiotherapist whether you really do need that test.

While medical tests might seem simple and harmless, they are not. There are three possible downsides that may have to be weighed up before you take a test. First, tests themselves can cause physical and psychological side effects, like infection or anxiety. Second, tests can give unreliable results, perhaps suggesting that you need treatment when you may not. And finally, having a simple, common test might mean you end up being labelled as having a disease or dysfunction that you may have to live with for the rest of your life. Sometimes such a label can help open doors to valuable treatments like effective drugs, but other times we can end up being labelled as sick and suffering from any number of new disorders, when we may in fact be in reasonably good health. For all these reasons it is worth thinking very seriously before having any tests done, asking whether they really need to be done, and whether there might be some better alternatives.

The aim is not to avoid tests altogether, because so many of them can be helpful. The aim instead is to try to avoid the ones that are not needed. But whether a particular scan or blood test is necessary, is not always clear. Different people will react differently to the same information about the benefits and downsides of having any given test. The point is to try to get as much information as possible to help you make the most informed decision. While we all have a natural curiosity and often want to know all we can about what might be wrong with us or our loved ones, having a test can sometimes lead us down potentially rocky pathways we never really needed to step onto.

Tests themselves can cause serious harm. As the example on CT scans in this chapter shows, common tests that use radiation—like X-rays and CT scans—are strongly suspected of causing cancer. It is very shocking to learn that you only need to have a small number of these scans before you start to raise your risk of cancer. Unbelievably, the common X-ray has recently been classified as cancer-causing and labelled as a ‘carcinogen’ by the World Health Organization.

Apart from physical harm, there is also the psychological anxiety that can arise when you get a test. As many of us know, waiting for the results of a test for serious illness can be agonising.5 Even if the results come back normal, many people are understandably still not reassured and continue to worry for a long time afterwards.6 But if the test wasn’t warranted in the first place, all that worry has happened unnecessarily. The whole process of testing can be much more onerous than we imagine.

Tests can start us down a pathway to more tests and then to potentially risky or unproven treatments. In the second example on the PSA blood test, which is widely used to help diagnose prostate cancer in men, we see that even commonly used tests can be unreliable. Many test results are not black and white, but rather very uncertain in terms of what they actually mean, despite the fact that doctors often appear certain when they tell you about them. And unreliable tests can sometimes lead to a false diagnosis—or an all-clear that is unwarranted. You can’t rely on doctors or other health professionals to automatically tell you about the uncertainties surrounding many tests; often it’s up to you to ask questions like: ‘Do I really need this test?’

Even the simplest of tests can produce results that will change our lives forever. The third example in this chapter examines a blood test for cholesterol levels and highlights how having a test can result in a medical label that you may wear for the rest of your life. Sometimes receiving a correct diagnosis and a label is absolutely necessary, because it can lead to valuable treatments. But sometimes that label might actually be unhelpful, because it can cause people to think of themselves as sick or diseased when they are in reality healthy.

Example 1: CT scanning

The reason radiologist Steven Birnbaum was so concerned about his daughter receiving too many CT scans is that they involve large doses of radiation. Computerised tomography Tests can produce results that will change our lives forever scans are used all over the body, from the head and chest to the stomach and heart. Unlike ultrasounds or MRIs, which use different methods of seeing inside the body, CT scans, X-rays and nuclear medicine tests all use radiation. One CT scan can give a dose of roughly 10 units of radiation (a unit here is referring to a millisievert, or mSv). Yet just 50 units of radiation, the amount received from five CT scans, may lead to an increased risk of cancer later in life.

Much of the evidence about cancer risk comes from studies of survivors of the nuclear bomb explosions in the Japanese cities of Hiroshima and Nagasaki, who were exposed to radiation at the end of the Second World War. More research on this is needed because exactly what dose of radiation will increase your risk of cancer, and by how much, is still uncertain. The point here is not to cause alarm about the CT scans or other tests that you or your loved ones may have had in the past. Rather the aim is to encourage scepticism regarding the tests that you might be recommended in the future.

For many years there have been concerns about the radiation people are exposed to when they receive X-rays and CT scans, but now mainstream medical associations are taking the issue very seriously indeed. In 2007, the conservative American College of Radiology released an alarming paper on the potential dangers of radiation, produced by a special panel which included Dr Steven Birnbaum.9 Because of the massive increase in the number of tests being done, the paper described a ‘significant increase in the population’s cumulative exposure to ionizing radiation’. Will this lead to an increase in the rates of cancer? The paper was uncertain but stated, ‘the presumption is that it will’.

As that document outlines, there is still uncertainty about how serious these dangers are, and there is an urgent need to start doing more research to find out what harm these scans are doing to people. There are ongoing doubts about what doses of radiation many machines give out, and about how much radiation is absorbed into different parts of the human body. The document also states that many doctors who order tests for their patients do not even think about the dose of radiation that their patients will receive. While some doctors are very knowledgeable, it says that others ‘have had little or no training in radiation exposure and do not routinely consider this factor when ordering imaging examinations’. The report urges radiologists themselves to be more open with their patients about the potential cancer risks of tests like CT scans.

As anyone who has had a scan recently would know, trying to meet and talk with the radiologist who reads your scan result is almost impossible, let alone ask them questions. Tough questions really need to be put to the doctor, physiotherapist or chiropractor who is referring you for a CT scan, for example: ‘Do I really need this test?’ and ‘Does the test itself involve any potential drawbacks or side effects?’ These questions are even more important when a health professional recommends that a child be scanned and exposed to radiation. The dose of radiation that children receive from CT scans can vary enormously, and there are growing concerns that too many children are receiving too many scans, exposing them to too much radiation.

Significant concerns about too much radiation are the potential long-term damage to a child’s development and the increased risk of cancer. In 2006, a Canadian auditor-general heavily criticised hospitals in one province after discovering an excessive use of CT scans on kids. Problems included hospitals not using special settings for smaller bodies, and failing to monitor the size of the doses and the number of scans children received. The auditor-general’s report also referred to a survey of Canadian doctors, revealing that over 90 per cent of them underestimated the radiation dose that children received from a CT scan.

While there are moves underway to try to reduce the number of CT scans and the amount of radiation that children and adults are exposed to, these scans remain big business. Doctors, private hospital companies and medical centres will not give up precious profits without a fight. In the United States, X-rays and CT and other scans are called ‘diagnostic imaging tests’—and when you add them all up, they make a US$100 billion a year industry.13 Many individual doctors own the testing machines they have in their offices, which means they benefit directly whenever they recommend that test to a patient. There is very good evidence to show that when a doctor has a financial interest in ordering a test, they will order a lot more of them. Normally such behaviour would be seen as something like an illegal ‘kickback’ but, under a special exemption in the law, doctors are allowed to do it.

Similarly, in Australia, the large companies that own local medical centres may also own testing equipment and pathology laboratories. That means there is a financial incentive for the medical centre owners to encourage their doctors to send patients for tests, as we will hear more about in chapter 9, ‘Who else is profiting?’.

In recent years, many specialist radiologists in Australia have formed themselves into highly profitable companies, which have invested heavily in million-dollar machinery like CT scanners. These doctors have an obvious interest in earning profits from those machines, which means having the maximum number of people come through the door every day for a test. There is a lot of pressure out there in some sectors of the medical marketplace to take a CT scan, and growing evidence that too many of us may be having them. In fact, a recent study in Australia suggested that perhaps two-thirds of all CT scans of the chest may be inappropriate. One way to protect against unnecessary and potentially dangerous scans for you or your children is to ask beforehand very firmly: ‘Do I really need this test?’