How Do We Stop Screening When it No Longer Makes Sense?

By | December 18, 2019

As healthcare providers, we focus a tremendous amount of activity on screening to prevent illnesses. Whether it is cholesterol checks, mammograms, or colonoscopies, there is a time where the benefit diminishes due to the age or health of an individual. Currently, we are in a situation where screening continues past its efficacy. Therefore, how do we stop?

It is imperative to understand why it occurs. Without a doubt, it is challenging to have a conversation that can imply to a patient, “You are no longer worthy of screening or I am giving up on you since you are elderly or extremely ill, it will not make a difference.” Even if we directly quote the literature, it may translate to the patient, “it says don’t screen if you have less than ten years to live,” a conversation that doesn’t bode well for the patient or the physician.  Furthermore, information to consumers does not stipulate when screening is no longer valid. In an attempt to increase screening rates, we avoid the back end conversation to avoid muddying the waters.

Once again, the answer lies within the conversation and public messaging. If we focus on the discussion of benefit versus injury, we may be able to elevate the conversation. Generally, most people do not equate harm with screening, but undeniably, it occurs. Colonoscopy perforation is a perfect example where considerable damage can occur when the procedure should never have happened in the first place. How do we have conversations where the patient feels like they are receiving more care, not less?

An interesting aside is the discussion concerning the value of annual wellness visits for the Medicare population. At the inception of Medicare, reimbursement for these visits did not occur based on the belief that they simply did not matter given the life expectancy of that population at that time. However, over time, as we began to live longer, the thinking has evolved and determined there is significant value to wellness visits beyond just screening. That being said, these visits must focus on what should occur, meaning what is value-added versus what is not. They should concentrate on advanced directives and other conversations pertaining to issues of advancing age, and not just checking the box of what screening tests are needed, nor merely using that time to address chronic conditions. Therefore, we must question, is the yearly physical focusing on the correct issues?

We also need to contemplate and evaluate our current quality metrics and incentives. Are we being judged and incented to act in a way that is not efficacious? If I believe a screening is unnecessary, is the argument not to do it more cumbersome than just doing the wrong thing?  Including Medicare, our payors need to be part of the conversation as well. Finally, we need a more public health approach to raising awareness in the public domain that stopping screening is the right thing. It is not fair just to lay this issue at the feet of the physician when there is such a societal component of the conversation.