Sunday, March 10, 2013

Four Orthopedic Tests that might be Unnecessary but are Routinely Ordered


Some patients, especially those with HMO insurance, adopt a more-is-better approach to medical care, and this goes for doctors and patients alike. Armed with information from “Dr.” Google, and “Dr.” Wikipedia, or just plainly because they have medical insurance, some patients often demand tests that might not be necessary at all.

Sometimes, doctors are often all too willing to oblige.  While there is no doubt we, doctors, genuinely want to help our patients stay healthy, sometimes, we may also be motivated by malpractice fears. “What if she really had a tumor and I didn’t get an MRI?” Or they may have thought that ordering a test is quicker and easier to convince patient of his or her diagnosis, than sitting down with the patient and discussing the risks and benefits of his/her health situation.

The consequence of all this, of course, is that patients or insurance, may spend way too much on unnecessary tests. Unnecessary tests aren’t just costly. They take away the “clinical eye” of the doctor that really separates the great doctors from mediocre ones. In addition, some tests can also do real harm to patients. Although rarely, the procedure can be a physically invasive measure that can go wrong; other times, it exposes a patient to a potentially harmful substance, like radiation. In addition, a false positive can lead to anxiety and a cascade of unnecessary follow-up tests.

I recently had a patient who brought her MRI results showing me a full paragraph of the results.  She was anxious, of course, because she couldn’t understand the medical jargon. In her opinion, it was good she told her doctor to have the MRI right away because the MRI reading was so long and sounds scary. So what did I say about the results, as expected?

” Nothing.  Don’t mind that. It just means you are not a teenager anymore….”

The list below contains four screening tests that are commonly performed on orthopedic patients. These are tests or procedures whose necessity should be questioned and discussed thoroughly with your doctor before proceeding.

If your doctor recommends that you get one of the tests below, ask some questions to help you weigh the risks and benefits. I offer some suggested questions. Instead of asking “Doc, is that really necessary?”, ask instead “How would the results of this test change the management of my case, Doc?”; “Can we get this information by history and physical examination only?”; and perhaps the most versatile question of all: “Can this wait for a while or should it be done ASAP?”

1. X-rays
Some doctors, especially non-orthopedic surgeons, order x-rays left and right, as long as the chief complaint is pain.  Not all orthopedic patients need x-rays. There are cases wherein whether we see specific findings in the x-rays or not, the management won’t change. It may, however, help us rule out or exclude other causes of the pain. Remember that x-rays will mainly show us bone abnormalities.  And a thorough history and physical examination usually can get the diagnosis correct, without the need for x-rays.

2. MRI  
   A lot of patients or doctors insist on getting MRI if their clinical diagnosis is slipped disc.  But it is necessary to remind everyone that if you perhaps do an MRI on all people in the world, 20% might show slipped disc in the MRI, even if they have no symptoms. Unless you are planning to undergo surgery, MRI is usually not needed for diagnosis.

3. Uric acid test – A lot of patients come to orthopedic surgeons with uric acid results already, most of the time with normal results. Apparently, this has been ordered by their primary physician beforehand.  If the clinical suspicion is not gout, it is unnecessary.

4.       Peripheral bone-density scans for low-risk women –A lot of osteoporosis screening tests are just a pitch for leading anti-osteoporosis drugs, and orthopedic doctors wanting to get more patients.  If this is offered free, then you may want to undergo. But unless a woman has risk factors for osteoporosis, women shouldn’t get a baseline bone density test until at least age 65. (Risk factors for osteoporosis include having a family history or previous history of fractures, small bone structure, early surgical menopause, etc.) Too often, however, women without any risk factors get this test. Many are then diagnosed with osteopenia, a diagnosis that refers to low bone density. This condition may never develop into osteoporosis, but women with the diagnosis can find themselves undergoing a lifelong regimen of costly drugs that carry side effects, from gastrointestinal distress to the rare jawbone problem or even “atypical” thigh fractures.

Women who are found to have osteopenia but don’t want to take medications, can talk to their doctors about taking calcium supplements and doing more weight-bearing exercise.

Summary
Deciding when to do a procedure or screening test can involve as much art as science, because behind those illnesses and scientific evidences are real patients with real feelings and demands. There are few hard and fast rules, and medicine is not an exact science. Much of the necessity of the tests depends on the risk profile of the patient. Doctors and patients should work together to find the right balance. “Otherwise, there’s no end to the tests we can do, the harm we can cause, and the money we can spend. “

The tendency to over-diagnose and over-treat is often a result of doing unnecessary tests. Giving financial incentives to doctors to deliver more efficient and cost-effective care, is probably a step in the right direction.

What do you think?

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