Medical care in the US is the most expensive in the world, but almost all our health outcomes are worse than other industrialized countries. We talk a lot about US populations that don’t have enough access to medical care, but this post is about people who get more medical care and procedures than they need. It turns out that too much medical care not only adds to costs, but is actually as bad for you as not getting enough medical care. I’m going to write about both diagnostic and surgical procedures that are unnecessary at best, and dangerous at worst.
Unnecessary Diagnostic Tests
Routine lab work at your annual preventive care visit
It is common for doctors to order “routine” lab work at preventive care visits. This often includes a complete blood count (CBC), a comprehensive metabolic panel (CMP), a lipid panel and a hemoglobin A1C (a long term blood sugar test).
Healthy people who are not overweight and have no symptoms don’t need any of these, except perhaps the lipid panel to screen for high cholesterol but not even that every year. If you are overweight and sedentary, then it makes sense to screen for diabetes or pre-diabetes with an annual hemoglobin A1C. If you have high blood pressure then it makes sense to do a basic metabolic panel, which includes a measure of kidney function once a year. Other lab work should be based on symptoms and risk factors.
One reason that doing unnecessary lab work is dangerous as well as costly is that the more tests you do on someone, the greater the statistical chance that at least one of them will be abnormal. That can lead to a cascade of further tests and even dangerous procedures.
Imaging for low back pain
There is no reason to do x-rays. CT scans or MRI scans for acute low back pain unless it lasts for more than 6 weeks. Imaging should be done sooner if “red flag” symptoms are present such as:
- Fever or chills
- Recent illness or surgery
- Recent severe back injury
- History of cancer
- Unexplained weight loss
- Night pain or pain at rest
- Urinary or fecal Incontinence
- Saddle anesthesia (loss of feeling in the buttocks and inner thighs)
- Weak, numb, or painful leg muscles
Abnormalities on imaging, especially CT and MRI are often present in people who have no back pain. Imaging without red flags, could lead to unnecessary surgery or back injections.
CT or MRI scan for headache with no findings on neurologic physical exam
Headaches are common and the vast majority do not have a serious cause. Headaches without any other symptoms or history of head injury do not need any imaging. Headache in people who have a history of migraine headaches also do not need imaging. There are certain “red flag” symptoms that do require an immediate CT or MRI scan. These include:
- Abnormal neurological examination (e.g. papilledema, altered mental status).
- Signs of systemic illness (e.g., fever, stiff neck, rash).
- Worst headache ever.
- Progression in frequency and severity of headaches.
- New headache in patients older than 50 years.
- Sudden onset of headache – “thunderclap headache.”
- New-onset headache in an immunocompromised or cancer patient.
- Headache after head trauma.
- Headache worsening with Valsalva (straining like you do to have a bowel movement).
DEXA scan for osteoporosis in low risk women before age 65 and in low risk men before age 70
The risk of fractures due to osteoporosis is extremely low in women under 65 and men under 70 who have none of the high risk factors outlined below. DEXA scans in people in this low risk population are not only unnecessary but also result in unnecessary radiation exposure. Radiation exposure is cumulative and can increase the risk of cancer.
Risk factors for osteoporosis include: a family history of osteoporosis, previous fractures, dementia, poor nutrition, cigarette smoking, alcoholism, low weight and body mass index, estrogen deficiency, early menopause (i.e., before age 45) or prolonged lack of menstrual periods in premenopausal women, long-term low calorie intake, history of falls, and inadequate physical activity.
Ultrasound of carotid arteries (carotid dopplers) in people who have no symptoms
People who have no symptoms are unlikely to benefit from carotid stents or surgery even if they have partial obstruction of the carotid arteries. They are much more likely to be harmed by surgery including risk of stroke, heart attack, or even death.
Carotid dopplers are only indicated for people who have symptoms suggestive of a stroke or mini stroke (TIA)
Routine PSA screening for prostate cancer in men
Although a few men’s lives will be saved by routine PSA testing, many, many more will have surgery for slow growing prostate cancer that would never affect their health, resulting in urinary incontinence and sexual dysfunction for a good portion of those.
PSA screening for prostate cancer should always involve shared decision making with the patient. Some people who have a strong family history of prostate cancer or other risk factors may opt for screening. It should never be routine.
Prostate cancer screening should not be done at all in men over 70. The chance of finding anything other than low grade prostate cancer that does not need treatment in men over 70 is very low.
Annual EKG’s (or any other heart screening test) in low risk people without symptoms
Heart screening tests, including resting EKG and exercise stress testing in people in a low risk population have a much higher false positive rate than true positives. This can result in unnecessary invasive procedures including cardiac catheterization and unnecessary heart surgery.
People with multiple risk factors might benefit from screening tests. Here is a link to a heart disease risk calculator: CV Risk Calculator. You will need to know your LDL and HDL levels to use this calculator. If your 10 year risk is over 10%, you might benefit from one of the heart disease screening tests.
Pap smears under age 21 and over age 65
A pap smear is a screening test for cervical cancer, which is caused by chronic infection with the HPV (wart) virus. Women under 21 who are infected with HPV most often clear it without treatment. It therefore makes no sense to screen women under 21 for cervical cancer. Women over 65 whose last pap smear or HPV test was normal have almost zero risk of contracting HPV, so no longer need pap smears.
Annual pap smears are no longer needed for anyone. Pap smears are recommended every 3 years for women age 21-29 and every 5 years from age 30-65 as long as an HPV test is done also.
Unnecessary Procedures
Stents for stable angina
Stents in the coronary arteries can be life saving for heart attack or unstable angina (heart pain that is getting progressively worse). Many people, however have stable coronary disease. They get pain with a predictable amount of exercise that goes away when they rest. It stays the same and does not get worse with time. People with this kind of stable heart disease do just fine when treated with medicines and lifestyle changes. They do not need stents. In fact, stents do not decrease all cause mortality (death) 4 years later compared to treatment with medicines. Some studies suggest that up to half of coronary stent insertions are unnecessary. Stent insertion is an invasive procedure that can have complications including death. You definitely don’t want to have one if it isn’t likely to extend your life significantly.
Hysterectomy (removal of the uterus) for benign disease
Most “elective” hysterectomies are done because of fibroid (benign) tumors, excessive vaginal bleeding, or endometriosis. All of these conditions have alternative less invasive effective treatments. Fibroids that are causing symptoms can be removed without a hysterectomy. Persistent vaginal bleeding can be treated with hormones or with removal of the lining of the uterus without doing a hysterectomy. Endometriosis can usually be treated effectively with hormones. Hysterectomy should be done only for cancer or when alternative treatments for benign disease have been tried and have not been effective.
Knee arthroscopy for arthritis
Osteoarthritis of the knee is one of the most common chronic healthcare conditions. It involves gradual deterioration of the joint surfaces including tears of the menisci. Knee arthroscopy involves using a tiny camera to look inside the knee through a small incision. Another small incision is made to insert small surgical tools. When orthopedists recommend this procedure to patients, they often say that they are going to “clean out” the knee. This means removing fragments of torn cartilage and pieces of meniscus.
People get temporary relief if any from this procedure. It is considered unnecessary surgery. It exposes one to the risks of general anesthesia and possible infection from the procedure.
Vertebroplasty for osteoporotic compression fractures
Compression fractures of the spinal vertebrae are relatively common in women (or men) with osteoporosis. Many times these are not painful and are found incidentally on x-rays. Sometimes they are painful, especially when they first happen. Vertebroplasty involves injecting cement into the fracture site to stabilize it and reduce pain. Most of the time short term pain medicines and temporary spinal braces provide adequate pain relief. There have been no well conducted double blind studies of vertebroplasty, so it is not known how much of the pain relief from this procedure is simply a placebo effect. It may help in very selected patients, but should only be done for persistent pain when conservative measures have failed.
Spinal fusion for back pain
Chronic back pain is a common condition. It can result from arthritis of the spine or can still be present even with normal x-rays. Spinal fusion surgery connects two or more spinal vertebrae together with small screws. Bone chips from the hip bone are used at the site of surgery as a bone graft, which eventually fuses the vertebrae together.
Spinal surgery of any kind, but especially spinal fusion is never appropriate for people with chronic back pain who have normal back x-rays. Osteoarthritis of the lower back, which does show up on x-rays, is best treated conservatively with physical therapy, non-narcotic pain medicines and walking as much as tolerated.
Spinal fusion is only indicated when there is severe instability of the spine that is causing pressure on the spinal cord. This is not a common finding, so spinal fusion is only rarely indicated.
One problem with spinal fusion is that there is increased mobility of the spinal facet joints above the level of the fusion, which can cause recurrent pain. This can lead to another fusion, which is caused by the first one.
Bottom Line
Unnecessary diagnostic tests and lab work increase the probability of unnecessary surgical procedures. You should ask your doctor or nurse practitioner the reason for any diagnostic tests or lab work that they order. If the answer is “routine” then you should consider declining the test.
If any elective surgery (that means not emergency surgery) is recommended you should ask if there is a more conservative option. You may also always request a second opinion. For any of the low value procedures outlined above you should be very wary of having that procedure unless you have one of the red flag indicators.