During the 2015 NBA finals, Kyrie Irving, the Cleveland Cavaliers star guard, sustained a season-ending knee injury. According to news reports, an MRI “revealed the injury,” and Irving was scheduled for surgery to repair a fractured patella.
I have spent all of my adult life learning and practicing musculoskeletal medicine, and I know that a patellar fracture can be diagnosed without an MRI. But stories about high-profile athletes who get an MRI study for every tweak of an ankle or a knee or shoulder are common.
If sports teams want to spend their money for MRI studies, that’s their business, but this practice sends the wrong message to the general public. Contrary to popular belief, an MRI does not magically reveal the diagnosis but is simply a confirmatory step that follows taking a history, administration of a physical, provocative testing of the area in question, and review of routine radiographs. For most orthopaedic conditions, an MRI is simply unnecessary.
Some years ago, I decompressed the median nerve in an acquaintance of mine. He had a very satisfactory result and did well until recently, when he began to experience more troublesome symptoms of carpal tunnel syndrome in his opposite hand. The orthopaedist he saw indicated that a complete evaluation, with lab tests, by his primary care physician was necessary prior to surgery. Is this preparation really necessary for a 10- to 15-minute operation performed under local anesthesia?
Is it overkill?
My focus on this type of overtesting was recently reemphasized by an article in the New Yorker by Atul Gawande. The article begins by saying, “Millions of Americans get tests, drugs, and operations that won’t make them better, may cause harm, and cost billions.”
Similar statements have been made by numerous authors and medical societies in recent years, both here and abroad. Here’s another example: A commentary in the Journal of the American Medical Association (July 1, 2009) cited an estimate by E. S. Fisher that “perhaps one-third of medical spending is for ‘services that don’t appear to improve health or the quality of care—and may make things worse.’” The Dartmouth group has given similar estimates. And reports from the Institute of Medicine (IOM) indicate that up to 25,000 Americans die each year of gastrointestinal bleeding associated with the use of NSAIDs.
As surgeons, we should be aware of the widespread nature of overtreating and overtesting in the American medical culture. Americans have the most expensive health care in the world, but our health is no better than in many other countries with lower healthcare expenditures. Dr. Gawande describes a study of more than 1 million Medicare patients that indicated that a huge proportion of those patients had received care that was simply a waste.
American physicians overtest and overtreat. We do this for a variety of reasons, one of which is that patients expect and demand to be tested and treated. We all know that antibiotics are not indicated as treatment for a viral upper respiratory infection, but patients insist that they need antibiotics at the first sign of the sniffles or a sore throat. And we too often willingly accede to their demands.
“Doctors largely decide what medical or surgical treatments are needed, whether it will be delivered in a hospital, what tests will be performed, and what drugs will be prescribed or medical devices implanted,” claimed an editorial in the New York Times in 2009. “There is disturbing evidence that many do a lot more than is medically useful—and often reap financial benefits from overtreating their patients.”
To address this issue, the American Medical Association (AMA) and The Joint Commission cosponsored the National Summit on Overuse in 2012. This summit brought together representatives from 112 physician organizations, government agencies, research institutions, and labor groups to develop recommendations to curb overuse of five medical interventions or treatments.
That same year, the ABIM Foundation launched Choosing Wisely®—asking national medical specialty organizations to identify commonly used tests or procedures that patients and physicians should question and discuss. The goal was to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.
The AAOS list includes the following:
- Avoid performing routine postoperative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
- Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.
- Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
- Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
- Don’t use postoperative splinting of the wrist after carpal tunnel release for long-term relief.
What can we do?
I’m sure each of us could develop a similar or better list. For example, the benefits of viscosupplementation are equivocal at best, and vertebroplasty has recently come under scrutiny. Arthroscopic débridement of arthritic knees has been shown to provide no benefit in at least one major study. More than one study has shown high levels of positive MRIs in asymptomatic patients—whether for conditions in the cervical spine, the lumbar spine, or the knee.
Surgical procedures are undoubtedly overused across the spectrum—from coronary bypass procedures to total knee arthroplasty to prostatectomy. Approximately 200,000 ACL reconstruction procedures are performed each year in the United States at a direct cost of $3 billion. Are they all necessary? A recent study in Sweden suggests that for young adults, a strategy of rehabilitation plus optional delayed reconstruction, or in some cases no reconstruction at all, equals the results of early ACL reconstruction.
Even a simple procedure such as excision of ganglions may have an effect on costs. A recent study proves that no purpose is served by submitting the surgical specimen for evaluation by the pathologist.
Radiology studies are a huge drain on the healthcare budget. Many orthopaedists have met patients who show up with their MRI on a disc but have never had a simpler and cheaper plain radiograph. And, of course, such studies are not only costly but also present real hazards to patients. Radiation doses from computed tomography scans, for example, are 100 to 500 times greater than those from conventional radiographic studies.
There is broad agreement that an unknown, but substantial, fraction of imaging examinations are unnecessary and do not positively contribute to patient care. According to one analysis, several interrelated factors have promoted the nonbeneficial use of imaging, including habit or anecdote, patients’ desire for more imaging, financial interests of physicians who own imaging equipment, and concern about liability risk. A recent survey of Massachusetts physicians found that 28 percent of diagnostic imaging referrals represent defensive practices.
Is the root cause of unnecessary imaging the “style and content” of medical education, as has been suggested? If so, an educational effort to change the way we practice is needed. Similarly, in an effort to cut down on the massive amount of waste and inefficiency in health care, the IOM is recommending that “physicians and other health professionals become part of a ‘learning’ system that uses new clinical support tools that link performance to patient outcomes.”
Domestic medical tourism is a current hot topic. As Dr. Gawande explains it, “several large corporations such as Wal-Mart are sending their employees who may need spine, heart, or transplant procedures to certain ‘centers of excellence’ for their surgery, often flying the patient across the country for an evaluation and treatment.” He goes on to note that the company wasn’t doing this “out of the goodness of its corporate heart,” but because it hoped to save money.
Surprisingly, however, after 2 years, reports Dr. Gawande, “the biggest savings and improvements in care are coming from avoiding procedures that shouldn’t be done in the first place. Before the participating hospitals operate, their doctors conduct their own evaluation. Those doctors are finding that around 30 percent of the spinal procedures that employees were told they needed are inappropriate.”
Implications for all
In thinking about overtesting, overtreating, and the possible harm that can come to individual patients, we must also consider the immense financial implications for our healthcare system—not only the expense of these tests, but also out-and-out fraud. In 2009, government-wide “improper payments” totaled $98 billion—more than half of it paid by Medicare and Medicaid.
As physicians, we must all constantly examine our prescribing practices; inform patients that all they hear on television is not gospel and that they don’t need antibiotics for the common cold or an MRI for a sprained ankle; and keep a watchful eye out for fraudulent practices. A couple of years ago, U.S. News and World Report listed the following five questions that patients should ask their physician when the doctor whips out a prescription pad or keys in an e-prescription:
- Why am I getting this drug (or test?)
- What are the risks versus benefits?
- Is there an older drug or lifestyle alteration that works just as well?
- Will it interfere with my other medications?
- Does this drug prevent real clinical events?
Good questions—not only for patients, but for us as well. Perhaps if we as physicians constantly asked ourselves these same questions, the issues of overtesting and overtreating would be less onerous.
George L. Lucas, MD, is a member of the AAOS Ethics Committee. He can be reached at firstname.lastname@example.org
- Gawande A: Overkill. New Yorker, May 11, 2015. Accessed July 24, 2015
- Fisher ES: More medicine is not better medicine. New York Times. December 1, 2003:Opinion. Accessed March 25, 2009
- Kilo CM, Larson EB: Exploring the harmful effects of health care. JAMA. 2009;302(1):89-91. doi:10.1001/jama.2009.957. Accessed July 24, 2015
- Schwartz AL, Landon BE, Elshaug AE, Chernew ME, McWilliams JM: Measuring low-value care in Medicare. JAMA Intern Med. 2014;174(7):1067-1076. doi:10.1001/jamainternmed.2014.1541. Accessed July 24, 2015.
- Doctors and the Cost of Care. New York Times, June 13, 2009. Accessed July 24, 2015.
- Hillman BJ, Goldsmith JC: The uncritical use of high-tech medical imaging. N Engl J Med 2010;363:4–6. July 1, 2010DOI: 10.1056/NEJMp1003173. Accessed July 24, 2015.
- Massachusetts Medical Society: Investigation of Defensive Medicine in Massachusetts, November 2008. Accessed July 24, 2015.