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