What your doctor doesn’t prescribe, but should: a healthy dose of skepticism. (Hero Images/Getty Images)
Just as you hope your mechanic will only propose the tune-ups that your car truly needs, you trust that your M.D. will suggest procedures that your body really requires. But, alarmingly, that may not always be the case — in a 2014 survey, 72 percent of docs said the average physician prescribes an unnecessary test or procedure at least once a week.
The primary reason the surveyed doctors cited: a fear of being sued. “Sometimes doctors will order tests or even do procedures just to make sure that nobody can accuse them of not doing everything,” says Richard A. Deyo, M.D., a professor of evidence-based medicine at Oregon Health & Science University and co-author of “Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises.” (In fact, 91 percent of physicians said that reforming malpractice laws would reduce unnecessary tests and procedures.)
But there’s also an element of compassion at play: When patients are pleading for a cure, doctors want to provide it — even if it doesn’t necessarily exist. “We’re inclined to look for a silver bullet,” Deyo says. That might mean performing unnecessary (or even ineffective) surgery — a decision that can also have a financial motive. “In our current insurance situation, most doctors get paid more for doing more,” he says. “So there’s really not much of an incentive to hold back.”
Of course, not all doctors are consciously trying to steer you toward unnecessary care. But that doesn’t mean you should accept every treatment offered. “A skeptical attitude is always good,” says Deyo. “Patients need to be asking questions.” You should be especially inquisitive if your doctor prescribes one of the following five procedures:
1. Knee arthroscopy
If you have osteoarthritis of the knee, your doctor may suggest arthroscopic surgery to shave off the rough, inflamed cartilage and rinse out the joint fluid that contains inflammatory chemicals, says Deyo. What sounds like a promising way to combat pain may actually be pointless: In two randomized controlled trials, patients received either a knee arthroscopy or a sham procedure. “They basically put the arthroscope in the knee, but didn’t actually do the repair,” says Dr. Jeremy Sussman, who served on the Society of General Internal Medicine’s Choosing Wisely task force in 2013.
Both studies found that knee arthroscopy was no more helpful than the placebo procedure. In fact, one of the studies, published in The New England Journal of Medicine, showed that the surgery didn’t add any benefit to a well-thought-out regimen of physical and medical therapy (e.g. pain meds).
2. Imaging for new low back pain
We get it: Back pain is a pain. And the discomfort can easily drive you to try anything your doctor recommends. But be warned: Undergoing an MRI or X-ray for a new case of low back pain may just lead you down a road of unnecessary treatments.
Low back pain is extremely common, its causes are usually benign, and the pain will often resolve on its own, says Sussman. But if you undergo a scan, you may walk away with an entirely different impression: “The problem is that many normal, pain-free people have terrible-looking MRI scans — for example, things like bulging or degenerated discs that are really a sign of aging, like wrinkles or gray hair,” Deyo says.
When these scary-looking results show up on a scan, “both doctors and patients can find them alarming,” he says. “That may set off a cascade of more tests and treatments that actually aren’t very helpful.” The result? The overuse of imaging for low back pain may contribute to the two- to three-fold increase in surgical rates seen in recent years, according to a paper in the Journal of Orthopaedic & Sports Physical Therapy.
So when should you accept a scan? If your back pain is accompanied by weight loss, you’re age 65 or older, you recently had an infection or took steroids, or you have a history of cancer, then your low back pain could be a sign of something serious, says Sussman. In those cases, an MRI or X-ray is warranted, since it’s important to determine the underlying cause of your pain.
3. Cardiac stress test
Stress tests are designed to gauge your heart’s ability to withstand strain: You exercise on a treadmill or stationary bike, and your doctor monitors things like your heart rate and blood pressure. It all sounds pretty benign, right? One problem: “Stress tests are not terribly accurate and can certainly be misleading,” says Deyo. “There are both false positives and false negatives. So the patient might be falsely reassured by the test or falsely alarmed by the test.”
In a 2013 study in the Annals of Surgery, researchers found that the rate of unnecessary stress testing before surgery — e.g. in people without risk factors for cardiac trouble on the table — is on the rise in older patients. “Age alone is not a reason to get one,” says Sussman. “And neither is a low-risk surgery —for example, if someone is going to have cataract surgery, they almost never need a stress test.”
It’s not just pre-operative stress tests that are being performed unnecessarily: Doctors may be over-prescribing them for patients with chest pain, too. Although stress tests are key for patients with chest pain related to heart disease, they’re of little use to those with chest pain caused by musculoskeletal or gastrointestinal issues, says Deyo. However, if performed in these patients, they may compel doctors to perform unnecessary follow-up care.
4. Complex spinal fusions
If you have spinal stenosis (narrowing of the spine), your doctor may propose a drastic solution: welding two of your vertebrae together. And a JAMA study of Medicare claims suggests this is occurring with increasing frequency: Although the overall rate of surgery in older patients with spinal stenosis declined over the five-year study period, the rate of complex fusion procedures increased 15-fold.
Why that’s worrisome: “For most patients, a simpler operation is all they need — that is, just a decompression-type surgery,” says Deyo. It’s not just in complexity that the procedures differ: Spinal fusion costs nearly 3.5 times more than decompression surgery, according to the JAMA study.
So why the push for major surgery? Doctors often use screws and rods to hold the bones in place while the vertebrae heal — and unfortunately, they may be under the influence of the salesmen pushing those tools. “The hardware has been aggressively marketed, because it’s highly profitable,” Deyo says. “The manufacturers have gone to some lengths to persuade surgeons that, in nearly all circumstances, they ought to be doing fusions.”
5. Annual pelvic exams
Nearly 70 percent of gynecologists believe pelvic exams are an effective way to screen for ovarian cancer, according to a 2012 study in Preventive Medicine. Yet earlier this year, the American College of Physicians (ACP) issued a new guideline: Pelvic exams — the genital checks gynecologists perform with a speculum — should no longer be done on asymptomatic, non-pregnant women. (Note: This doesn’t include pap smears.)
It’s simply a case where the harms outweigh any perceived benefits: The exams are embarrassing and potentially painful for the patient, and they actually aren’t a highly accurate tool for diagnosing ovarian cancer or bacterial vaginosis, according to the ACP.