At the Mall

“Isn’t it a bit unnerving that doctors call what they do ‘practice?’”
-George Carlin  


My bad.  

A few months ago, on a day when I was already in a sour mood, I walked past the kiosks at the local mall trying to fend off the sales pitches — “No, I don’t need a phone;” “No, thanks, but I don’t need basement waterproofing;” “Thanks, but I already have a watch.” Suddenly, a pleasant, young woman with a lip piercing approached me.  

“Sir, would you like to learn how a scan can save your life?”  

Here, I was told, was an opportunity to use the very latest technology to check me for heart disease, screen me for many types of cancer, and make certain I was free of dangerous gall stones. The testing would be painless, I wouldn’t have to remove my clothes, and a package screening deal would allow for enormous discounts. My insurance company might even pay for some of the testing! She smiled and looked at me hopefully.  

I guess I snapped. “Are you aware that the screening tests that your company sells have never been shown to be effective?” She regarded me with surprise. With as much composure as I could muster, I tried to explain that neither the CT angiogram nor CT lung cancer screening had ever completed clinical trials testing. Over the next couple of minutes, I’m pretty certain I moved on to telling her what I thought of the company for which she worked. “You should think twice about this job,” I recall saying. She turned away and I mumbled an apology. Pretty soon, she had buttonholed another potential customer.  

I admit that I was embarrassed by my rant. The encounter resurfaced in my memory when I read an article entitled “Weighing the Costs of a CT Scan’s Look Inside the Heart” in The New York Times (June 29, 2008). The authors much more eloquently make the same case that I tried to make with that unfortunate saleswoman. Undoubtedly, doctors who have embraced the technology clearly disagree with doctors who have called for more research and evidence. Still, the article notes that a “faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques.”  

There are risks, of course. The article cites an expert who calculated that a CT angiogram uses the same amount of radiation as over a thousand conventional chest X-rays. On top of that, Americans spent over $100 million on 150,000 CT angiograms last year. Those volumes will only rise in the future.   

Whenever we are putting our patients at risk, either medically or financially, it seems to me that we should always try to act based on what we know is true rather than what we only wish was true. One of my medical school professors told our class many years ago, “Half of what we teach you in Medicine is wrong. The problem is this: We don’t know which half.” Some days, it seems like what we really, truly know is even less than that.