Want to know what doctors really think about the way other doctors practice medicine? I sure do… insider information is always valuable, so I was intrigued to learn what physicians have to say about medical tests and procedures prescribed by their peers that are seen as unnecessary… not particularly meaningful… or even “bad medicine,” as they say in doctor parlance. The National Physicians Alliance (NPA), an organization that seeks to improve US health care, recently asked its 20,000-plus members, all doctors, to identify cost-saving, efficiency-improving practices in family, internal and pediatric medicine. The results — published in the May 23, 2011 online edition of Archives of Internal Medicine — may surprise you because they include many tests and procedures that are routinely prescribed.
It turns out that all too often, doctors keep doing things the way they’ve always been done, even when new research or guidelines establish that there is a better way to treat a particular problem. Why? According to Stephen Smith, MD, professor emeritus at Brown University, who headed the NPA study, it can be hard to get doctors to change their habits even when new information casts doubt on their effectiveness. For some, it’s hard to break old habits… for others, it’s the belief — often mistaken — that it’s what the patients want… for still others, it may be a lack of awareness or knowledge… and, for a few, it may be that there is a financial incentive, not to mention the fear of liability if they miss something. And as patients, we aren’t blameless, either — we sometimes pressure our physicians to give us tests or drugs that we think (but don’t really know) make sense.
Dr. Smith and I went over the practices that peeve physicians the most and that came up most often…
Early imaging for low-back pain. Back pain ranks fifth among reasons why people visit the doctor — and all too many of those folks end up getting an MRI scan despite evidence showing that it’s not usually helpful. It’s not that MRIs are dangerous — unlike X-rays and CT scans (which use radiation), they’re not potentially harmful — but ouch, they’re pricey. An MRI typically costs about $3,000, Dr. Smith said. Most lower back pain improves on its own within about six weeks. If it lasts longer or if nerve damage is suspected — for instance, if there is numbness in the groin or problems controlling urinary or bowel function — that’s when a doctor should consider an MRI.
Unnecessary antibiotics. According to Dr. Smith, even doctors admit that too many among their ranks still prescribe antibiotics to patients with colds — a practice they all know doesn’t help. Colds are viral, and antibiotics work only against bacteria. They should be prescribed only when a person is sick for a week or longer (as a general rule) or if there are certain specific reasons to suspect a virulent bacterial infection, such as Group A streptococcus, which can lead to strep throat.
Annual cardiac screening for patients with low risk and no symptoms. Too many doctors prescribe yearly electrocardiograms for adult patients with no signs, symptoms or particular risk factors for heart disease. Dr. Smith said it might make sense to order a one-time ECG at around age 40 to serve as a baseline if needed for future comparison… or more often if the patient has a job that stresses the heart particularly (pro athlete, firefighter) or where public safety is an issue (airline pilots, train conductors, bus drivers). “But there’s no need to keep repeating it year after year,” Dr. Smith said, noting that even subtle changes in ECGs typically take years to turn into dangerous heart problems.
Pap smears on women younger than 21 or who have had a hysterectomy for any reason other than cancer. Dr. Smith said that it is common for young women to exhibit abnormalities of cell appearance that then tend to disappear within a few years on their own… and it is meanwhile very rare for a woman so young to develop precancerous changes rather than transient inflammatory changes. Also, research has demonstrated that Pap smears are simply unnecessary for women who have undergone hysterectomies for benign disease. Of course, women who have a family history of cancer should discuss with their doctors whether they should continue Pap smears.
Bone-density tests on women under age 65 and men under age 70. There’s no evidence that bone-density tests prior to these ages provide meaningful information unless there are other signs of trouble — such as a personal or family history of fracture, small build, low body weight, prolonged use of corticosteroids or calcium deficiency, smoking, alcoholism or other factors, Dr. Smith said. And what information is gained frequently is interpreted too negatively — with the result that doctors often put patients on a lifelong path of bone medication that can have serious adverse side effects. Exceptions to the NPA’s age guidelines: Men under 70 who have particular bone risk factors, such as loss of height, change in posture, sudden unexplained back pain or a nontraumatic fracture.
Blood and urine tests for healthy adults without symptoms of a problem. Often prescribed as part of the routine physical exam, these tests are not particularly helpful or important except for patients with worrisome symptoms such as fatigue or high blood pressure. Why? The likelihood of picking up kidney or liver disease is quite slim, but the odds of false-positive results that would lead to yet more unnecessary testing is fairly high. The exception: People with total cholesterol higher than 200 mgdL and HDL at least 40 mg/dL should be tested every one to two years or according to your doctor’s advice, while others should be tested every five years said Dr. Smith, adding, “When called for, a patient can then be treated with diet and lifestyle changes and, if necessary, medication.”
Brand-name statins to reduce cholesterol. “For the large majority of patients who really need statin drugs, generic varieties such as simvastatin, lovastatin and pravastatin are perfectly adequate. And they cost only a few dollars a month,” Dr. Smith said. In contrast, brand-name statins (such as Lipitor, Mevacor, Pravachol) can cost more than $150 a month. Since each statin drug works slightly differently, some people may need to use a brand-name version because the generic versions are not effective for them, while others have such dangerously high levels of cholesterol that they need the “big guns.” But, says Dr. Smith, this doesn’t happen very often.
If your doctor engages in one of these “worst practice” behaviors, voice your concern. There are exceptions to every rule (and we’ve noted a few important ones above), but if a doctor has no particularly good reason for why he or she is advising you to do something on this list, it may be a good reason to start looking for another doctor.
