The safest course of action in the Covid-19 pandemic may not be to stay home as much as possible — not if you’re having symptoms of a stroke or heart attack or even if you have other health care needs that have been postponed for the last six months. But in yet another massive public health failure in the US, we still have no clear messaging about the relative risks and benefits of going to the doctor.
University of Pennsylvania infectious disease doctor Harvey Ruben said medical professionals have taken great care to keep patients safe — giving everyone a mask, for example, and using temperature checks at the door. There were some coronavirus transmissions in health care settings early on, mostly between health care workers who didn’t have adequate protective gear. That’s improved now, but for some patients, he says, telemedicine is still a better option.
That’s not because the office visit is particularly dangerous, but because telemedicine was a good option even before the pandemic started. For many kinds of visits, it saves everyone time. So why weren’t we doing this years ago? Insurance companies and other payers have been reluctant to reimburse people for telemedicine visits, he says. That may change in the post-pandemic world, along with the rise of work-from-home policies in other industries.
Still, there are screenings and surgeries and other kinds of exams that have to be done in person. Is it worth the risk to go? It depends. Some medical procedures are lifesaving, or alleviate suffering, and others are unnecessary — or even harmful.
In a way the pandemic has been a natural experiment, since almost all routine health care in New York City was put on hold for several months last spring, says cardiologist Sandeep Jauhar. After the hiatus, his patients looked far healthier than he expected, he says. It’s an observation he made in June in a New York Times piece titled, “People Have Stopped Going to the Doctor. Most Seem Just Fine.”
Which is not to say all medical care is unnecessary, and he emphasized that fear of the pandemic may have indirectly caused deaths or complications in people who didn’t seek medical care for serious conditions. His point is that doctors need to get serious about overtreatment.
Treatment varies by geography in a way that can’t possibly reflect differences in disease incidence. In Minnesota, he says, there’s a seven- to ten-fold difference in the number prostatectomies by region — with no reason to suspect prostate cancer rates vary that much.
Many diagnostics are ambiguous. Patients may prefer to be treated even if there’s only a small chance they have a dangerous condition. Doctors may err on the side of action, too. Even when compelling evidence shows a treatment isn’t saving people, it can be hard to give it up.
Paul Offit, an infectious disease doctor, lays out some of the risks of overtreatment in his new book “Overkill: When Modern Medicine Goes Too Far.” He shares data showing that heart stents, antibiotics and some cancer screenings are overused to the point of causing harm.
Thousands of people have undergone unnecessary surgery, radiation or chemotherapy for suspected breast or thyroid cancers that never would have killed them. Not all slow-growing tumors should be considered cancerous. “Cancer to me is something that if left untreated, you die from,” he says.
Mammograms can save lives, but also have downsides — including a high rate of false positives. Surgery or chemotherapy might not be worth it for cancers that aren’t deadly. And thyroid cancer screening is even more problematic.
Thyroid cancer diagnoses have skyrocketed in the last 30 years with the advent of new tools, including ultrasound machines and needle biopsies. Diagnosed cases tripled in the United States and grew by a factor of fifteen in South Korea, where an extensive cancer screening program offered cheap tests. The number of thyroid surgeries exploded along with this apparent epidemic, but to the surprise of the medical establishment, after taking out all those thyroids there was no decrease in deaths from thyroid cancer. Some of the suspected cancers were false positives and many were slow-growing and unlikely to be deadly.
Meanwhile, unnecessary treatment does harm. In some cases, doctors permanently damage a patient’s vocal chords or the nearby parathyroid gland. A number of medical groups now recommend against routine thyroid cancer screening, but that hasn’t helped, says Offit. Financial incentives may play a role, and the doctors’ beliefs that they are saving lives.
The good news is that for things like a routine check-up, many people may be served just fine by getting blood work done and then having a teleconference with the doctor.
But the decision to get in-person care is complicated. It may depend on your risk factors for getting severe Covid-19, and the risk factors of people you live with, combined with the risks of skipping a test or treatment. The risks also depend on infection rates in a given region. It might turn out to be better to take care of important but non-urgent medical needs while cases are low in the Northeast, but better to wait out surges in hotspots.
The risk of getting Covid-19 from your doctor looks to be low. Enough time has gone by to estimate how many people, if any, have gotten infected with Covid-19 from an eye exam or dental appointment. This is where the public health community needs to gather all the available data and share it in a way that’s calm, reasoned and useful — so that nobody with a serious medical condition suffers or dies from staying home too long.
Bloomberg
