Unnecessary Medical Tests (November 4, 2014)

This is one aspect of modern medical care that we encounter time and again. It’s common -- unnecessary medical testing cost well over $7 billion in 2011. But it’s not the cost that is really the issue here (although anyone who has ever had to pay for an unnecessary test should be angry about it), but the other problems that can result.

These problems aren’t just the possible health risks from the test itself (although those are quite real and I will mention a few of them below). It’s the anxiety that results from thinking that something might be seriously wrong and then all the further testing and procedures that the patient can be dragooned into if that test appears to show something suspicious.

People in general are way too blasé about unnecessary medical testing. There is a tendency to believe that a test may be unnecessary, but that they are somehow safer for it having been done. Part of that “more care means better care” fiction. This is NOT true, and here is a specific example for illustration.

Suppose you take a long car trip, and driving for hours into the sun ends up giving you a splitting headache that lasts a couple of days. Your mother talks you into going to an M.D. for it, and for some reason you actually go instead of just shining her on and going to see your chiropractor instead. Any good M.D. will listen to your story, ask you a couple more questions, maybe do a quick exam, then kick you out of the office with a bottle of aspirin and instructions to go to your chiropractor like you should have done in the first place. A CT scan of your head is NOT indicated at this point and the reasons it should not be done are:
 

• It’s very expensive. Someone is paying for it, even if you aren’t. 
• It’s exposing you to unnecessary radiation (up to 300 times that in an average chest x-ray), and radiation dosage is cumulative.
• It’s not going to give any insight into your headache, which is clearly from muscle tension. 
• If the scan is done, there easily might be a funny little shadow or unusual formation seen on it. Because you have no signs that there is anything at all wrong with your brain, anything that looks odd is millions-to-one going to be completely benign in nature, but you will have the crap scared out of you and you may be subjected to a lot more testing and maybe even a procedure or two, all unnecessary AND all carrying their own risks. (I will never forget a young mother of my acquaintance who spent several days in terror because her stupid internist mistook a normal variant for pathology on an unnecessary brain MRI.)

Consumer Reports (I really like their medical advice, by the way) identifies four particularly overused testing situations. Unnecessary CT scans and MRIs for headaches are one. The other three are:
 

• EKGs and exercise stress tests. If you don’t have heart disease and are not at high risk for it, these should NOT be part of your standard physical examination.
• Bone density (DEXA) scans for osteoporosis. A not-uncommon finding of some mild bone thinning often results in completely unnecessary treatment for osteoporosis. Before age 65 for women (and 70 for men) these should not be done without reason.
• Xrays, CT scans and MRIs for lower back pain. In 2007, 2.2 million CT scans were done for lower back pain in the United States, and one study projects 1200 cancer cases resulting from those scans. (I was very glad to see this one on the list by the way. When I graduated chiropractic college back in the Stone Age, the standard of care for spinal pain was mandatory x-rays before manipulation. If a chiropractor skipped doing these because they weren’t warranted and there was the SLIGHTEST difficulty down the line of any kind, not having done x-rays was automatically malpractice. This is no longer the case, and we are all glad of that.)

There is a lot that you can do for your own health, but you can’t suddenly become an expert on all the possibilities when a problem lands you in the doctor’s office. So here are questions to ask about any “further testing” that is suggested that will help you avoid any that may be unnecessary:

• Why are we doing this test?
• What will the findings tell us about this problem?
• Will the test results change how we treat the problem? 

By the way, if a test is negative, that doesn’t mean that it was unnecessary.  It’s simply that in order to do any test, but particularly an expensive and/or invasive one, you should have a good reason. Do not buy that nonsense about poor persecuted doctors forced to do unnecessary testing on their patients in order to protect themselves from mean old malpractice attorneys. Any doctor who orders unnecessary imaging because s/he is too lazy or stupid to do a proper examination should be avoided.

The thing is, doctors like to do doctor stuff. We didn’t become doctors in order to tell people to quit worrying about it and go home, even if that is the best thing to do. So it’s easy to get into the habit of over-testing. And here’s another thing. If you’ve spent the last 15 years of practice ordering angiograms for everyone who walks into your office with chest pain, and some study comes out telling you that you shouldn’t do that unless you have some other indication for it, that means you’ve been doing the wrong thing for 15 years. And people hate to think that they’ve been doing the wrong thing for 15 years, especially when they are doctors. Five years after the definitive study came out establishing diuretics as the go-to drugs to treat hypertension, most doctors were still prescribing the more expensive medications that they had become accustomed to over the years. So don’t trust your doctor TOO much. S/he is only human, after all.

--dr. diane holmes
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