Testing in Medicine, Testing in Schools (Abigail Zuger, M.D.)

The following article appeared in the New York Times on April 13, 2015. I have often compared primary care physicians to teachers; sometimes the comparisons worked and sometimes they did not. This article looks at testing in both arenas, medicine and schooling.  Abigail Zuger compares school-based standardized tests and her work one day of spending five hours seeing 14 patients and ordering 299 diagnostic tests. Do you agree with the analogy she draws? Why?

I spent the usual long afternoon at work doing little but ordering tests, far more than I honestly thought any patient needed, but that’s what we do these days. Guidelines mandate tests, and patients expect them; abnormal tests mean medication, and medication means more tests.

My tally for the day: five hours, 14 reasonably healthy patients, 299 separate tests of body function or blood composition, three scans and a handful of referrals to specialists for yet more tests.

Teachers complain that primary education threatens to become a process of teaching to the test. They wince as the content of standardized tests increasingly drives their lesson plans, and the results of these tests define their accomplishments.

We share their pain: Doctoring to the tests is every bit as dispiriting.

Some medical tests, like blood pressure checks, are cheap and simple. Some are pricier and more complicated, like mammograms or assays for various molecules in the blood that correlate with various diseases. We order them all at prescribed intervals, and if we happen to forget one, either by accident or design, electronic medical records nag us mercilessly until we capitulate.

As in education, our test-ordering behavior and our patients’ results increasingly define our achievements, and in the near future our remuneration is likely to follow. Still, like all test-based quality control systems, ours can be gamed. Our tests can also inflict unnecessary psychic damage, and occasional physical damage as well.

Most distressing: Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.

It is all in the name of good and equitable health care, a laudable goal. But if you reach age 50 and I cannot persuade you to undergo the colonoscopy or mammogram you really don’t want, am I a bad doctor? If you reach age 85 and I persuade you to take enough medication to normalize your blood pressure, am I a good one?

I am not the only one who wonders.

A cadre of test skeptics at Dartmouth Medical School specialize in critically examining our test-based approach to well adult care. If you are confused about mammography, colonoscopy or the PSA test for prostate cancer, these folks deserve much of the blame: They have repeatedly demonstrated that these tests and many others do not necessarily make healthy people any healthier, any more than standardized testing in grade school improves a child’s intellect.

Dr. H. Gilbert Welch, a Vermont physician who is part of the Dartmouth group, has a new book that might serve as the test skeptic’s manifesto and bible. Its title, “Less Medicine, More Health,” sums up his trenchant, point-by-point critique of test-based health care and quality control.

In medicine, “true quality is extremely hard to measure,” Dr. Welch writes. “What is easy to measure is whether doctors do things.” Only doing things like ordering tests generates data. Deciding not to do things and let well enough alone generates nothing tangible, no numbers or dollar amounts to measure or track over time.

Dr. Welch points out that doctors get to become doctors because they are good with tests, and know instinctively how to behave in a test-focused universe. Rate them by how many tests they order, and they will order in profusion, often more than the guidelines suggest.

They will do fine on assessments of their quality, but patients may not do so well. Even perfectly safe tests that are incapable of doing their own damage may, given enough weight, trigger catastrophe.

Yes, little blood pressure cuff over there in the corner, that means you. The link between very high blood pressure and disease is incontrovertible, and the drugs used to control blood pressure are among the cheapest and safest around.

Even so, as Dr. Welch pointed out in a recent conversation, systems that rate doctors by how well their patients’ blood pressure is managed are likely to invite trouble. Doctors rewarded for treating aggressively are likely to keep doing so even when the benefits begin to morph into harm.

That appears to happen in older adults, at least in those who avoid the common complications of high blood pressure and continue on medication. One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, withdeath rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster.

Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds. Not yet, at least. Someday, perhaps, not ordering and not prescribing will mark quality care as surely as ordering and prescribing do today.

Children go to school to learn. Adults go to the doctor … why? If they are sick, to get better, certainly. But for the average healthy, happy adult, let’s be honest: We really haven’t completely figured out why you are in the waiting room. And so we offer a luxuriant profusion of tests.



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8 responses to “Testing in Medicine, Testing in Schools (Abigail Zuger, M.D.)

  1. Dr. Mark Taormino

    I always like the analogy made between teachers and doctors, and that of testing is indeed another interesting take. A big issue though in education is that the current form of Common Core has consequences for the provider, aka teacher. In medicine, the test reveal underlying conditions, which a doctor may or may not ‘cure’. In education, the tests demand a ‘cure’, measured as demonstrated mastery of the measured content. While doctors are not held to absolute cure remedies, teachers are, or at least that is the way the wind prevails currently. Many teachers are going to be evaluated on the CC results, partly or in whole. Teachers are not being evaluated on practice, analogous to physicians. That’s the big disconnect. Surely, measurement is essential in any learning environment, but learning is much less beholden to cause and effect when compared to medical practice.

    Yes, too much testing has diminishing returns, but we need to test in education. However, to leave the result on the doorstep of the teacher borders on the absurd. The extraneous variables of motivation, parental involvement, local and home environment, and on and on, cannot be teased out of just raw test scores. The scores are a blip in time in the overall development of the student. As really just one piece of a complex puzzle, holding the teacher singularly accountable, is/will be a fruitless endeavor. A student receives instruction and feedback through a school, but the other environmental factors and parental guidance are also primary keys. That’s hard to fix, so we test, and blame. Instant gratification for some, but largely not useful.

    Could one imagine if doctors were judged and/or compensated on final outcomes? Diabetes because you are overweight? Eat terribly? Smoke? It is the doctors fault? How silly.

  2. Humm…5 hours,14 patients, 299 tests ordered. This does not add up to the teacher experience, nor reflect the current testing climate in education. I know of no teacher who works with only 14 students over the course of five hours. We work with 30+ students all-at-once and all day, or 100+ students over the course of the day in the case of middle & high school teachers. Then there is the issue of ordering tests vs. preparing students for and administering the tests to classrooms of students all at once–all the while attending to physical and emotional needs of students, trouble shooting computer glitches during testing, managing expectations of students, parents, & administrators, etc.

    For the analogy to work (and I am not certain it really can), the nature of the testing must be more similar (It is a stretch to compare a mammogram to the Smarter Balanced/Common Core assessment.), and there must be a better understanding of the role of being a classroom teacher.

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