How to Steer Toward the Path of Least Treatment By RONI CARYN RABIN The first doctor Lynn Munroe consulted about her hyperactive thyroid gland recommended radioactive iodine treatment to destroy the gland, followed by a lifelong regimen of thyroid hormone replacement pills. The second physician she consulted said that he could operate, removing the gland without radiation, but that she would still need to take the pills. A third doctor suggested a more cautious approach, prescribing medication to depress the gland¡¯s activity. It worked: Ms. Munroe, 49, a publicist in West Nyack, N.Y., no longer has symptoms of hyperthyroidism, even though she has been weaned off the medication. ¡°And I still have my thyroid intact,¡± she said. ¡°Thank God for third opinions.¡± Has American health care become overly aggressive? Many primary care doctors think so, according to a survey published last week in Archives of Internal Medicine. More than 40 percent of 627 primary care doctors who responded to the survey thought their own patients were overtreated; only 6 percent thought the patients received too little care. Why so many tests and referrals? Limited time to spend with patients, fear of being sued and financial incentives to do more were among the reasons cited by the physicians. Patients often worry about the cost of overtreatment but fail to recognize the potential harm of undergoing too many tests and procedures, said Dr. Brenda Sirovich, lead author of the study and a faculty member of the outcomes group at the Veterans Affairs Medical Center in White River Junction, Vt. ¡°I think we don¡¯t talk with patients enough about the fact that there is an optimum amount of medical care, and when you start giving too much, there¡¯s definitely a risk that it¡¯s going to be harmful,¡± Dr. Sirovich said. In Ms. Munroe¡¯s case, all three of the options presented to her are appropriate treatments for a hyperactive thyroid, and all have pros and cons. But despite its invasiveness, irradiation is more commonly used than medication to suppress production of thyroid hormone. Irradiation is considered the definitive treatment; it is also more lucrative. Dr. Rita Redberg, editor of Archives of Internal Medicine, a journal that has been publishing a series of papers on overtreatment, said the trend in medicine has been toward running more diagnostic tests and using more invasive procedures, even when tests may not be called for and equally effective, less invasive treatment alternatives may be less risky and less costly. ¡°Why is the most aggressive treatment becoming the standard of care?¡± Dr. Redberg asked in a telephone interview. ¡°We know that when patients are given a choice between surgery and a medical treatment, they almost always opt for the least invasive, least aggressive treatment.¡± Dr. Redberg and other experts have also been critical of what they see as the overuse of medication, including the increased use of opioids for chronic pain; the long-term use of proton pump inhibitors, linked to severe magnesium deficiency and other side effects, to manage acid reflux disease; and the widespread prescription of statins for patients without coronary artery disease, despite well-known adverse effects of the drugs. In one study published in the journal, doctors who reviewed the charts of elderly patients were able to discontinue nearly half of their medications without any detriment to the patients. But the idea that less is more is controversial, especially when it comes to heart disease. Many cardiologists say that cholesterol-lowering statins, for instance, can save healthy patients with risk factors from developing heart disease in the future. ¡°If you don¡¯t interrupt the atherosclerotic process, it builds up over decades,¡± said Dr. Roger S. Blumenthal, director of the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins. ¡°You don¡¯t want to sit back and wait until people have a fatal heart attack or stroke, because you often don¡¯t get a second chance. It¡¯s a very extreme position that makes absolutely no sense.¡± On the other hand, Dr. Blumenthal agrees that computerized tomography (CT) coronary angiograms of asymptomatic people do not improve care or outcomes. Here are a few things consumers can do to ensure they¡¯re getting appropriate treatment. Patients often want to know whether a test or procedure is covered by insurance, but other questions are more important, said Dr. Steven Woloshin, co-director of the outcomes group at the Vermont V.A. hospital and an author of several studies on overtreatment. ¡°A patient should ask, ¡®Why do I need this test? What do I get out of it? What¡¯s my chance of something bad happening if I don¡¯t get the test, or if I do get the test?¡¯ ¡± Dr. Woloshin said. Make sure you know about all of the different treatment options available, and the pros and cons of each. Remember that medication may be as effective as more invasive treatments. Balance the risks of any test or procedure against the potential benefit, given your medical history. Less-invasive, low-tech screenings with a lower risk of complications ? a fecal occult blood test, for instance, instead of a colonoscopy ? may be appropriate for some patients. If a CT scan is recommended, ask about an alternative that might result in less radiation exposure. If you take medications on a regular basis, have your doctor review your drug regimen periodically. Ask whether you may be able to wean yourself off a drug like a proton pump inhibitor if you make diet or lifestyle changes. Drugs that have been on the market longer often are better understood and have better safety records than newer drugs, whose adverse effects may not come to light until they have been available for some time.