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MD gets direct mail about screening – says she “can’t stand this anymore” a la Howard Beale

Hanna Bloomfield, MD, MPH, is Associate Chief of Staff, Research for the Minneapolis VA Healthcare System.

She usually writes scholarly articles.

But when she recently got a piece of direct mail urging her to pursue cardiovascular screening she felt she didn’t need, she decided to write a commentary in the local newspaper.

The Star Tribune published her piece, “Don’t be lured into unnecessary medical tests: If you don’t have symptoms, some medical screenings can lead to risky complications.”  It began:

“As I was flipping through the mail the other day, I noticed a flier from my medical clinic offering vascular screening. It warned me that “vascular disease often shows no symptoms or warning signs until it’s at an advanced stage and difficult to treat.” It encouraged me to call the clinic to schedule three tests — an ultrasound of the belly to look for a bulging aorta, another one for blockages in the carotid arteries to my brain and blood pressure readings to check for leg artery blockages — for an out-of pocket cost of only $150.

The mailing did not encourage me to ask my doctor if I needed these tests. But since I am a primary care physician, I know that as a woman who has never smoked and who has no symptoms of any of these conditions, I should not get these tests.”

I encourage you to read the entire commentary.  She explains the potential harms of getting screened.

I called Dr. Bloomfield and asked why this issue got to her – enough to motivate her to write her commentary in the newspaper.

Howard Beale Mad as HellShe described it as a Howard Beale-like moment.  Beale was the network anchorman in the movie, Network, who urged viewers to open their windows and holler, “I’m mad as hell and I’m not going to take this anymore.”

In Bloomfield’s own words, she remembers that when she saw the direct mail piece, she felt, “I can’t stand this anymore.”

She wasn’t wild-eyed like Howard Beale; she was being rational. She said, “I felt somebody needed to write something about these screening promotions in lay language.  It’s counterintuitive – hard for people to understand.  But we need to try.”

So she wrote in the newspaper:

“Isn’t an ounce of prevention worth a pound of cure? In some situations, absolutely — for example, screening for colon cancer in older adults or for hypothyroidism in newborns. In these cases, evidence has shown that the benefit of screening a population outweighs the harm. But for many other screening tests, including the ones offered in the flier, the harm outweighs the benefits.

You might wonder how a test like an ultrasound could cause harm. Here’s how: If that initial harmless test is abnormal, you may be told that you need another test for follow-up. And so begins the testing cascade, often culminating in an invasive confirmatory test like an angiogram. And if that is positive, surgery might be recommended to fix the problem. Angiograms and surgery can cause kidney failure, strokes, bleeding and even death.

You might be willing to accept these risks if you knew that diagnosing the problem and getting it fixed while you are still feeling fine would lead to longer or improved quality of life. But in many situations, people do just as well or better if they don’t do anything until they become symptomatic, and many never become symptomatic.”

In the newspaper piece, she also challenged the health care clinic that sent the vascular screening promotion.  Then she wrote to the clinic’s chief medical officer stating, “I’m disappointed in you.”

After her Star Tribune article appeared, she got a letter from that same chief medical officer that basically said, “You’re right.  This is contrary to our mission and values.  I’m going to discontinue this campaign.”

But her commentary didn’t sit well with Dr. Jay Cohn, director of the Rasmussen Center for Cardiovascular Disease Prevention at the University of Minnesota. Cohn wrote a letter to the editor of the Star Tribune, “Why cardiovascular screening matters, even without symptoms.” Excerpt:

“Dr. Bloomfield needs to know that even “as a woman who never smoked and who has no symptoms,” for her atherosclerosis may be progressing and a future heart attack or stroke may be lurking.”

Dr. Bloomfield thought that line about “lurking” was classic fear-mongering.

That was my impression as well.  It reminds me of an ad (below) from a Pfizer campaign years ago in Canada – an ad that also used that fear-mongering “lurking” term.

cholesterol fear-mongering

Here are a couple of reader comments left on the Star Tribune website:

  • Well, they have to pay for their fancy, new or remodeled clinics somehow. I found it interesting that I got the same sort of mailings – right after my clinic went through an extensive remodeling. Same with my dentist. They remodeled that office and all of a sudden, I needed a bridge replaced, at $4,500 out-of-pocket, even though my dentist couldn’t provide proof that it needed replacing.
  • What is the downside to not knowing, what is the downside to a false-positive or a false-negative, what is the risk of complications for treatment……….all good things to know at the start of any medical tests.

We need to improve the public dialogue about health care – and specifically about the tradeoffs involved in any screening test.  There’s usually an imbalance in such discussions:  exaggerating or emphasizing benefits and minimizing or totally ignoring harms.

Imbalance in screening news

We can do a better job.  Kudos to Dr. Bloomfield for acting in her Howard Beale moment.

 

Addendum on June 26:  On a related topic, the Chicago Tribune published a story this week, “Experts question value of heart tests sold as potential life-savers.” It begins:

“In churches, community centers and businesses around Chicago, two national companies are setting up portable equipment and inviting people to buy cardiovascular tests that they say can help prevent strokes and heart attacks.

Life Line Screening, based in Ohio, advertises the heart and artery tests as a way to “do something about any health issues before it’s too late.” Florida-based HealthFair touts one test’s ability to prevent a stroke’s “devastating, irreversible effects to your quality of living.”

But major medical associations recommend that healthy people avoid several of the screenings, saying the potential harms from invasive follow-up procedures and overtreatment outweigh the benefit of spotting abnormalities before symptoms appear.

“People may be more likely to run into problems having the screening test done than if the test had not been done,” said Dr. Steven Weinberger, CEO of the American College of Physicians.”

 

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Comments (9)

Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Richard Huhn

June 26, 2015 at 9:31 am

I read Dr. Bloomfield’s essay in the Star Tribune the day it appeared. My first impression was that it was not strong enough on the risks of testing and didn’t go far enough in explaining the concept of overdiagnosis. But overall, I think the essay was a great public service. We need much more public education in this area.

Patricia Kirby

June 26, 2015 at 5:45 pm

Those medical screenings failed to tell me about my heart condition…….got taken but got smarter…I now ask for justification for testing even an Xray in the ER. And when told I needed cataract surgery in November I felt as though I was the way to this doc’s diamond bracelet for his wife….I walked out and got a second opinion and found I just need new glasses,…When we make Medical education and education itself affordable maybe we will get more doc’s like Bloomfield.

R Van Valkenburgh

June 27, 2015 at 8:31 am

Well done, Dr. Bloomfield! I wish stories like this were as newsworthy as the risk-mongering stories tend to be. Nonetheless, this helps to get the message out.
I also would like very much to commend the unnamed chief medical officer at the unnamed health clinic. It is rare to hear of someone retreating from their indefensible position. It takes a professional of high courage to change opinion/policy. Thanks again to Dr. Bloomfield for enabling this!

Brad

June 27, 2015 at 8:56 am

I find it just as interesting that hospitals…. and insurance companies charge differently…. cash pay for echocardiogram about a 1,000 bucks, hospital with insurance about 4,500 bucks…

Cerys

June 27, 2015 at 6:43 pm

High praise for shedding light on this issue. Medical marketing places huge pressures on patients and physicians. In a stress-based society, these messages exert a great deal of pressure pushing people deeper into anxiety and worry. Or, when overwhelmed, people retreat and don’t seek care. Also, TV ads and media bites create perceptions – mostly wrong – assumed by the public as representative of patient experiences. When they are not, the patient is blamed or ridiculed. The visual/auditory disconnect of portraying happy active people all while recounting a litany of adverse, possibly fatal, reactions is absurd at best. Local hospitals are not immune. Shrinking profit margins have administrators forcing physicians to hawk higher-profit testing and specialist referrals. I’ve confronted my doctors and they admit its just something they are instructed to mention, not a recommendation for me! With EHR reporting demands and quantity benchmarks, and the ACA focus on “preventative care,” this barrage is likely to continue. Along with the subsequent class action lawsuit circus hawking the evils of bad drugs… Ugh. Stop already, our health depends on it!

Phil Brewer, MD

June 29, 2015 at 9:56 am

I completely commend Dr. Bloomfield and agree that as physicians we need to speak up more when we see commercially motivated misinformation. One of my pet peeves is hospitals and urgent care clinics placing ads to induce people with flu symptoms into going to see a doctor. People with flu symptoms should go straight home and go to bed. They should also ignore all the Tamiflu ads which vastly overhype the effectiveness of antivirals to treat influenza, While at the same time under emphasizing the side effects. A couple of decades ago my own hospital put up a billboard encouraging people to use its three urgent care centers for flu treatment. I called the person responsible and told him I would resign if he ever ran ads like that again. Apparently it worked because the ads came down.

Beverly

June 29, 2015 at 10:26 am

Companies, clinics and hospitals promote unnecessary screenings and expensive, “state-of-the-art” technologies and treatments not to better people’s health, but to make a profit. That is the problem with our entire health care system: it’s all about profit.

Laurence Alter

June 29, 2015 at 2:13 pm

Dear Gary & Staff:
I notice you did not address Dr. Cohn’s objections IN THE LEAST.
All I read in objection (and not from you or your staff) was linguistic pedantics: that the word “lurking” was scare-mongering. Quite silly, really: to focus on one word that you interpret as melodramtic and catering to the public’s fears. Can’t you go beyond this and address Dr. Cohn’s substantive points? It just shows your unwillingness to debate concretely demonstrated arguments (one of which is the asymptomatic nature of C.V.D.).
Respectfully,
Laurence

    Gary Schwitzer

    June 29, 2015 at 3:01 pm

    Laurence,

    Who’s unwilling to debate?

    For women who have never smoked, the US Preventive Services Task Force recommends against routine Abdominal Aortic Aneurysm Screening, just as Dr. Bloomfield wrote.

    Regarding carotid artery stenosis screening, for the general population – not just for women – the US Preventive Services Task Force recommends against screening, just as Dr. Bloomfield wrote.

    And for the kind of peripheral blood vessel screening promoted in the direct mail Dr. Bloomfield received, the US Preventive Services Task Force “found no evidence that screening for and treating peripheral artery disease in people with no symptoms leads to better health in the future.”

    This is why painting a picture of “lurking” hazards is fear-mongering, and why it is not at all silly to call it that.