Medical testing has been in the news a lot lately, with all the discussions of health care overspending in the U.S., and controversies over what is an appropriate screening test.
Medical testing includes both laboratory tests, such as blood tests, as well as imaging tests, such as X-rays and MRIs. Consider lab tests. A few decades ago a lab might have offered 250 different tests. Now it is not uncommon for a large lab to run more than 4000 different tests. Many of these tests are obsolete, and have been replaced by better, more evidence-based tests, but the older tests are still offered. Even clinical chemists, who spend their professional lives studying testing, can’t agree on what tests should be phased out.
So how do you make sure you get the best medical tests done for yourself and your family, while avoiding unnecessary and even harmful testing? First, remember that medical diagnosis is an art as much as a science. It involves juggling all the unique elements of a patient’s individual history and exam, ordering the appropriate tests, and finally, interpreting the test results correctly.
There is also a campaign called Choosing Wisely that can help sort out what tests are worth having. Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation, in coordination with nine medical specialty societies, and Consumer Reports magazine. Each society was asked to formulate a list of five tests or procedures in their specialty that are still commonly performed, that should be questioned or abandoned. For example, the American College of Physicians (the medical society for Internal Medicine specialists) recommends against these five tests:
- Exercise stress tests in people without symptoms and at low risk for heart disease.
- Imaging studies for patients with non-specific low back pain.
- Brain imaging (CT or MRI) for evaluation of simple syncope (fainting).
- Imaging studies as the first test for deep vein clots (use a blood test called the D-Dimer first).
- Routine pre-surgery chest X-rays.
Also ask yourself these questions before a test:
- What are my options?
- What are the risks and benefits of each option?
- What happens if we wait or do nothing?
- What does this test measure?
- How will the results of this test change the course of my treatment?
- Who will contact me about the results, and what happens if they are abnormal?
These questions are appropriate for every patient (and every clinician) to ask before performing any test. Of course, asking these questions requires more time, patients are not used to asking them, and clinicians may not be used to answering them. Luckily the GreenField model encourages communication and interaction, so please ask us!
Seven Medical Procedures You Don’t Need
The Choosing Wisely campaign asked doctors in nine different medical specialty societies to each identify a list of five tests or treatments that they felt were overprescribed, overused and/or unnecessary in many circumstances. The AARP Bulletin did a wonderful job of choosing seven of the most popular, most overused tests and treatments, from all nine lists, for people over the age of 50.
To summarize their list:
- EKGs and stress tests for healthy people without symptoms. (American Academy of Family Physicians) Dangers: False positives often lead to more tests and invasive procedures. Exceptions: EKGs and stress tests may make sense for people with diabetes and/or other risk factors.
- Bone scans for osteoporosis for women under 65 and men under 70 with no risk factors. (American Academy of Family Physicians) Dangers: Bone density (DEXA) scans can lead to unnecessary medications that can have serious side effects. Exceptions: Talk to your clinician or physician about having such a test prior to age 65 for women and age 70 for men if you are or have been a smoker, if you have used steroid medications regularly, if you have low body weight, or if you have had a fracture.
- Antibiotics for mild to moderate sinus infections. (American Academy of Family Physicians: American Academy of Allergy, Asthma & Immunology) Dangers: The overuse of antibiotics can leave you vulnerable to increasingly virulent stains of drug resistant bacteria. Exceptions: Symptoms that last more than seven days or worsen after initially improving, or if you develop a secondary bacterial infection.
- NSAID painkillers for people with high blood pressure, heart failure and any chronic kidney disease. (American Society of Nephrology) Dangers: NSAIDS, such as Advil, Motrin and prescription medications such as Celebrex, are linked to stomach bleeding and increased risk of heart and kidney problems.
- CT scans and other imaging for uncomplicated headaches. (American College of Radiology) Dangers: Radiation exposure raises individual cancer risks, false positives lead to more testing and patient anxiety. Exceptions: Troubled speaking, blurred vision, weakness on one side or other symptoms may suggest a sign of stroke or tumor.
- Dubious diagnostic tests for suspected allergies. (American Academy of Allergy, Asthma & Immunology) Dangers: The superfluous use of medications; an overly restricted unbalanced diet.
- X-ray, CT scan & MRI for low back pain. (American College of Physicians; American Academy of Family Physicians) Dangers: Some tests expose people to unnecessary radiation and can lead to expensive back surgery. Exceptions: When the clinician or physician suspects serious underlying conditions or the pain isn’t better in six weeks.
(Originally published in GreenField Health Matters, 5/12; reviewed 8/14.)