Do You Need that Scan/Test/Procedure/Prescription?
Jancee Dunn, Vogue
A few years ago, after six weeks of ruthless back pain, I saw an orthopedist, hoping for a relieving jab of steroids. When he suggested an MRI, I was pleased at his thoroughness. I wasn't quite as thrilled when he told me that it could be a herniated disk. Within five minutes we were discussing the possibility of surgery. Friends soon bombarded me with tales of disastrous back operations. Chastened, I decided to try the natural route: daily exercise, ice packs, rest, and physical therapy recommended by my primary-care doctor. A month later, the pain receded.
Had my friends not intervened, I might have ended up under the knife. It was not clear that I even had a herniated disk. Magnetic resonance imaging, routinely ordered for back pain, produces impressively detailed pictures. But a host of recent studies have found that MRI's are easily misinterpreted-and, as a Johns Hopkins team reported in a study published earlier this year, "do not improve outcomes" for back-pain sufferers. Another study found that those who had an MRI in the first month of pain were eight times more likely to have surgery-but didn't recover any faster.
"The last time anyone can expect to see a textbook, normal spine is in teenagers," says Nortin M. Hadler, M.D., professor of medicine at the University of North Carolina at Chapel Hill. He says that these scans will almost always find something amiss. Backaches, he adds, not only are common ("If anyone goes a year without one, that's abnormal") but tend to go away on their own.
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And yet, doctors, leery of malpractice suits, use "defensive medicine" to cover their bases. Tests are extraordinarily lucrative. And, of course, demanding patients are also to blame: They want a flurry of action-a prescription, a test, blood work, a referral, or a combination of all four-not a "wait and see" approach.
But, in a movement that is galvanizing the medical world, that's just what a number of organizations are endorsing. In April, nine leading societies, as part of a campaign called Choosing Wisely, unveiled a list of 45 common tests and procedures, among them MRI's for back pain, that it recommends doctors perform less often. Many experts say this push back against technology-as-medicine is long overdue: Not only are these tests rocketing up costs (unnecessary treatment constitutes one-third of medical spending in the United States), but tests can have a high rate of false positives, which can subject a patient to a spiral of overzealous scans and potentially risky procedures that may not turn up a thing. In other cases, early detection may have no impact on the course of the disease.
"We're not saying these things should never be done," says Christine K. Cassel, M.D., president of the American Board of Internal Medicine. "We're saying that this is not one-size-fits-all and should be done only if the patient really needs it. People need to ask, 'What are the risks if I have this test? How about the risks if I don't?' " Here are a few tests, procedures, and treatments that doctors now think can be eliminated, cut back, or, at the very least, questioned.
Antibiotics for Sinus Infections
About one in five antibiotics prescriptions issued to U.S. adults is to treat sinusitis-often without even an office visit. But studies suggest that in most cases, antibiotics simply do not help. They only seem like they help because the infections typically clear up of their own accord during the time you're taking the medication. The best way to treat sinus infections is with over-the-counter pain relievers, fluid, rest, and saline nasal sprays. Bacterial infections (typically the culprit when symptoms persist for more than ten days) respond well to antibiotics, but according to Linda Cox, M.D., president-elect of the American Academy of Allergy, Asthma & Immunology, they account for less than 10 percent of sinus infections. For the rest, the thing the meds do most effectively is help build antibiotic resistance.
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Pap Smears and HPV Screenings
The time-honored ritual of the yearly Pap is now a thing of the past. The new thinking is that cervical cancer usually takes ten to 20 years to develop, so a Pap every three years works just as well. The American Cancer Society updated its guidelines to include HPV screenings, recommending that women start to get tested at age 30. HPV is highly prevalent in younger women, says Wanda Nicholson, M.D., associate professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill School of Medicine. "But most women under 30, with their strong immune systems, are highly, highly likely to clear it," she says. "So we don't need to expose that group to undue testing."
Dental X-rays
The amount of radiation in a dental X-ray is low, but a recent study from Yale found that people with a common noncancerous brain tumor called meningioma were twice as likely to report having had dental X-rays known as bitewing exams. The American Dental Association disputed these findings but, even so, issues conservative recommendations: Children should get one X-ray every one to two years, and adults every two to three years if they aren't experiencing dental problems.
When you do get one, the A.D.A. counsels people to request a leaded collar to protect the thyroid. Research linking the radiation from scans to thyroid cancer isn't definitive, but as Stephen Matteson, a research professor at the dental school at the University of Texas Health Science Center in San Antonio, says, "Why not put on a collar?"
Mammograms
Guidelines for mammograms vary depending on the organization. In 2009, the U.S. Preventive Services Task Force caused an uproar when it announced that women should have mammograms starting at age 50, and every other year thereafter. Screening earlier and more often, they argued, leads to too many false positives and unneeded biopsies without significantly improving odds of survival. This contradicted the American Cancer Society's long-held dictum that average-risk women should get a mammogram every year, from the age of 40, as well as the American College of Obstetricians and Gynecologists, which recommends a test annually.
At this point, many doctors offer their own guidelines. "I have dissected this for family and friends," says Margaret I. Cuomo, M.D., radiologist and author of A World Without Cancer. Her recommendation: Low-risk women aged 40 to 49 should talk to their doctors and get a baseline mammogram at 40 to determine if they have any risk factors, such as dense breasts. "It's a little-known fact," she says, "that the denser your breasts are, the higher your risk for breast cancer."
Women with elevated risks, she says, "need to be seen probably annually. Otherwise, you could go every two years." Cuomo adds that women with dense breasts should also request a digital mammogram and possibly an MRI, rather than the usual film screen, because it will be more sensitive in the detection of abnormalities.
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MRI's for Sports Injuries
In a recent, anonymous national survey, 96 percent of orthopedists admitted they had ordered tests or some other course of action that weren't medically necessary. To prove this point, a well-regarded Florida sports-medicine orthopedist scanned the shoulders of 31 perfectly healthy, pain-free pro baseball pitchers. The MRI's found abnormal shoulder cartilage-usually reason enough to operate-in 90 percent of them. Thankfully, a growing number of sports-medicine orthopedists are refusing to give MRI's, saying that a physical exam and, sometimes, an X-ray will suffice.
CT Scans
Computed tomography scans are a modern miracle. Widely used on the head and torso (limbs usually get X-rays or MRI's), they save lives by, for example, quickly scanning for internal injuries. "When I was an intern in the eighties, if you had symptoms of appendicitis, they operated," says Debra Monticciolo, M.D., chair of the American College of Radiology Commission on Quality and Safety. "And they were happy if only one in ten turned out to be appendicitis."
In the past fifteen years, according to a new report, the use of CT's has tripled, which means that Americans have been exposed to twice as much radiation from medical imaging as they were in the mid-1990s. CT scans can blast the radiation equivalent of up to 70 standard X-rays at once; they should be used for more urgent situations-not, say the Choosing Wisely panel, to explore milder conditions such as sinus problems, fainting spells, headache, or nonspecific abdominal pain (start with an ultrasound, which uses no radiation). And if your child is being examined, insist on a child-size dose of radiation. "Even a small adult should say, 'Can you use a lower dose for me?' " says Monticciolo.
Which is precisely what the Choosing Wisely panel advocates: Use your voice.
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