If there’s a shooting pain down your leg, or a piercing ache in your ear, or your hip occasionally catches when you walk, do you pick up the phone to call your doctor or, fearing a blitz of diagnostic testing, do you simply go about your business?
Many choose the latter course, according to John W. Davis, associate professor of urology at the MD Anderson Cancer Center in Houston, Texas. “With the wealth of treatment options available,” says Davis, “patients start to feel like guinea pigs, wondering why they’re being subjected to test after test and becoming more anxious with each procedure.”
It’s ironic that having the technology to uncover most bodily abnormalities can actually deter people from seeking care, but it’s not surprising, considering the findings of a recent study published in the journal Academic Emergency Medicine. Of the 435 emergency room doctors surveyed, 97 percent admitted to ordering imaging scans that weren’t medically necessary, and 85 percent said too many diagnostic tests are ordered in their departments.
A prime motivation was the possibility of missing an illness and being sued. Says Dr. Gregory Portera, a urogynecologist in Memphis: “The number one reason abundant tests are ordered is the threat of lawsuits.”
Dr. Hemal Kanzaria, the study’s lead author, and an emergency room physician at the University of California, Los Angeles, agrees.“We don’t like uncertainty,” Kanzaria told Health Day News, “and so we’re driven by this culture that says if there’s any doubt, we should do the test, and we don’t acknowledge the potential harms of this approach.”
Such as the possible harm of radiation. Even though simple sprains are far more common than fractures, many doctors routinely order X-rays on patients with ankle injuries.
Another risk of unneeded imaging, according to Kanzaria, is the possibility of a false positive. That can lead to biopsies, additional tests, and even potentially harmful treatments for a condition the patient doesn’t have.
“Physicians have learned to apply perspective and common sense to laboratory findings that are slightly above or below recognized measures,” says Dr. Gerald Corcoran, a family practitioner from Needham. “Hopefully, we’ll begin to apply these same value assessments to imaging results before we’re all aglow from radiation.”
In the not-so-distant past, a symptom would propel a patient to the doctor. Today, with technology, it’s increasingly common for benign conditions to be uncovered through diagnostics — conditions that aren’t troubling the patient and don’t always require treatment.
For example, it’s not unusual for MRIs to reveal bulging discs in patients without back pain. An ultrasound will sometimes detect gallstones in those who are asymptomatic. And whole-body scans reportedly uncover abnormalities in more than 80 percent of those who undergo them.
But how many of these “abnormalities” demand attention? How does their discovery affect our health and quality of life? How often do such findings lead to unnecessary treatment?
In 2012 the ABIM Foundation, along with Consumer Reports, launched the Choosing Wisely campaign with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures. Since Choosing Wisely started, about 430 tests and procedures have been reevaluated by medical societies ranging from the American Society of Clinical Oncology to the Society for Thoracic Surgeons.
The aim of Choosing Wisely is to spark conversations between physicians and patients about what care is needed. Recommendations circulated to care providers include:
“Don’t obtain imaging studies in patients with nonspecific low back pain.”
“Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.”
“Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis.”
The hope is that these and scores of other guidelines will serve as antidotes to those who reflexively reach for the nearest imaging device.
Since a patient can’t be expected to know the latest research — and absent malpractice reform to offset the impulse to “cover our backside,” as one doctor put it — the main safeguard against overzealous testing is something that doesn’t come easy to many on the gurney.
“Ask questions,” urges Davis, who has practiced urology for 11 years. “A good doctor won’t be offended.”
Questions like: What are the specific chances of finding a condition with advanced testing? What is the likelihood my condition will benefit from treatment? Is it feasible to actively monitor the condition?
And by all means, says the Anderson Center’s Davis, “Consider the classic question: ‘What would you do in my situation, doc?’ ”
For patients accustomed to deferring to medical authorities, summoning the courage to ask such questions is yet another test — a test of their ability to be assertive.
Jerry Cianciolo is chief editor of Emerson & Church, based in Medfield.