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Point and Counterpoint |

Rebuttal From Dr HalpernRebuttal From Dr Halpern FREE TO VIEW

Scott D. Halpern, MD, PhD
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From the Departments of Medicine (Division of Pulmonary and Critical Care Medicine), Biostatistics and Epidemiology, and Medical Ethics and Health Policy, Leonard Davis Institute Center for Health Incentives and Behavioral Economics, Perelman School of Medicine at the University of Pennsylvania.

CORRESPONDENCE TO: Scott D. Halpern, MD, PhD, University of Pennsylvania, 719 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021; e-mail: shalpern@exchange.upenn.edu


FUNDING/SUPPORT: This work was supported by a Greenwall Foundation Faculty Scholar Award in Bioethics and by a fellowship from the American Board of Internal Medicine Foundation.

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST the following conflicts of interest: Dr Halpern reports an intellectual conflict of interest related to his service as co-chair of the American College of Chest Physicians (CHEST) and American Thoracic Society Choosing Wisely Task Force in Pulmonary Medicine. He reports no financial conflicts of interest related to this manuscript.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):1149-1150. doi:10.1378/chest.14-1586
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Dr Simpson1 makes a compelling argument as to why, for the overwhelming majority of patients who do not meet the current criteria for lung cancer screening with chest CT scan, such scans should not be ordered. There is no evidence whatsoever that screening chest CT scans benefit patients who are not at high risk according to current guidelines. Dr Simpson makes the additional important point that the evidence base continues to evolve, and that following publication of ongoing and future trials, we may need to revisit whether even high-risk patients derive benefit, on average, from lung cancer screening. However, even if recommendations evolved such that there was no patient group for whom screening CT scans were recommended, one still could not conclude with certainty that no individual patient might benefit from such screening. Indeed, it is mathematically impossible to prove that screening cannot benefit a group of patients, let alone an individual patient.

This is not merely a theoretical problem of interest to statisticians; it has profound implications for medical professionalism. If we cannot say with certainty that an intervention cannot benefit a given patient, then promoting the social duties of physicians cannot be achieved simply by avoiding no-value care (ie, waste). Instead, responsible physicians must accept the fact that there is some small but unknowable chance that a decision not to screen a patient will be to forego an opportunity to provide high-value care for that particular patient.

In service of their social missions, physicians can and should be comfortable making decisions to forego services, such as lung cancer screening CT scans, that are low value on average when used outside of published guidelines. However, this responsibility to practice cost-conscious medicine need not also require physicians to turn off their brains and cease to consider the unique circumstances of an individual patient. Instead, physicians should use their specialized training to determine how well or poorly guidelines fit a given patient. Just as there are rare patients with congestive heart failure for whom β-blockers may not be appropriate, there may be rare patients at a low risk of lung cancer for whom consideration should nonetheless be given to obtaining a chest CT scan. The goal of improving the value of health care, and the essential roles of physicians in furthering this social mission, need not require cookbook approaches to clinical practice that place absolute prohibitions on clinical service use.

Acknowledgments

Role of sponsors: The sponsors had no role in determining the content of this manuscript or in the decision to submit it for publication.

Simpson T. Counterpoint: are there cases in which physicians should deviate from recommendations not to order a chest CT scan? No. Chest. 2014;146(5):1147-1149.
 

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Simpson T. Counterpoint: are there cases in which physicians should deviate from recommendations not to order a chest CT scan? No. Chest. 2014;146(5):1147-1149.
 
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