Doctors were told last month that we should stop doing so many screenings for prostate cancer with the prostate-specific antigen test. We learned that sigmoidoscopy is a cheaper, easier and effective alternative to colonoscopy for colon cancer screening. And a study I led turned up strong evidence that routine lung cancer screenings are justified only for people at high risk because of heavy smoking in the past.
Regular mammograms aren’t necessary for women in their 40s and are needed only every two years for women ages 50 to 74, the United States Preventive Services Task Force has decided. For many women, Pap smears are required only every three years, not every year, the group also says now.
This deluge of do-less recommendations results from research into tests and procedures that have been arguably overused. You’d think these pronouncements would bring a sea change in the way patients are treated in this country. But my guess is that little will change. Many doctors, maybe most, will ignore these findings and keep doing what they have been doing all along.
The PSA test will still be ordered as a matter of routine, not selectively administered after careful discussion with patients. Colonoscopy will remain the accepted primary method for colon cancer screening. Radiology centers will continue to offer lung cancer screening to people who are unlikely to get lung cancer.
Why? Health care critics are quick to point to the profit motive. And it’s true that gastroenterologists, radiologists, urologists and physicians of all stripes make money from procedures that may not be necessary. But the real obstacle is not money. It’s the culture of doctors, and that will be very hard to change.
In medical school, I was given textbooks and made to memorize long lists of obscure facts, most of which have never come up in practice. Then I sat at the knee of master doctors. I followed them around. I learned to emulate what they did and how they thought. Over the years, I gained some approximation of their mastery. At times, I’ve even found myself mirroring how they stood and leafed through a patient’s chart.
Subtly, and then overtly, I learned that as long as I trusted my instincts, I was probably going to be right. Because doctors know best.
Ours is a comfortable hegemony, particularly if you do not question it. It has teeth, too. A strong defense to a malpractice lawsuit is that you did what other doctors in your community would have done — the “community standard” test. Citing anodyne research written by faraway experts to back up your actions is a less preferable strategy.
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