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Question: I am 63 years old, have played a lot of sports and have had back pain, on and off, for about ten years. Unfortunately, it’s gotten a lot worse recently. I would like an MRI to find out what is going on. However, my family doctor says that because I don’t have any leg weakness or numbness, I don’t need an MRI. This bugs me. Is she just trying to save the health system money? What if I have a spine tumour?
Answer: Back pain certainly can be debilitating. I’m not surprised you want an MRI to know what’s causing the problem. But I doubt your doctor would deliberately deny you access to a test just to save the health-care system money. I suspect she thinks there’s not much to be gained from an MRI, based on her assessment of your current physical symptoms.
Still, you’re not the first person to question a doctor’s judgment or motivation. For that reason alone, it’s worthwhile checking out a fairly new website – www.choosingwiselycanada.org – which provides general guidelines about what tests, treatments and procedures are really necessary for individual patients.
It should give you a better understanding of the criteria for determining when an immediate medical intervention is needed.
The website was set up as part of the Choosing Wisely Canada campaign that officially launched earlier this year.
“This campaign is really about trying to increase conversations between doctors and patients about unnecessary tests and treatments and help remind people that more is not always better. In fact, more can be harmful,” says Dr. Wendy Levinson, chair of Choosing Wisely Canada, and a professor of medicine at the University of Toronto.
For a wide variety of reasons, she notes, we’ve slipped into a bad habit of doing tests and treatments that aren’t always justified. A physician may order tests as a precautionary measure – just to make sure all the basics are covered. At the same time, many patients have expectations they should get some type of treatment when they visit a doctor. Even if the physician feels a test or prescription isn’t warranted, it maybe easier to do something rather than explain to the patient why no action is required.
In many cases, patients get better without any medical interventions. Time is the great healer. However, unnecessary tests or treatments may actually subject patients to needless risks, says Dr. Levinson. For instance, CT scans and X-Rays involve exposure to radiation. Patients can also have allergic reactions to medications.
Furthermore, one test can lead to another. An MRI or CT scan might uncover some “inconsequential abnormality” and the doctor may feel compelled to order an invasive biopsy as a precaution. Going for the biopsy could raise the patient’s anxiety level. It might also cause discomfort or lead to an infection. “So a cascade of things can follow from a test that wasn’t needed in the first place,” she explains.
Choosing Wisely represents the combined efforts of a broad range of medical disciplines. Specialists from various fields got together to identify problem areas. In April, eight national medical bodies – plus the Canadian Medical Association – released a list of 40 tests, treatments and procedures that may be over-used and possibly causing needless harm to patients. More items will be added to the list as experts in other medical specialties complete their scientific reviews and find evidence of over-use, waste and potential harm.
Choosing Wisely is modeled after a similar U.S. campaign that made its debut two years ago. It was spearheaded by a foundation of the American Board of Internal Medicine.
Dr. Levinson, who has worked as a physician in both Canada and the United States, was also deeply involved in getting the American campaign off the ground. The U.S. effort involved a partnership with Consumer Reports, which put together explanatory materials that were posted online for patients and their families.
“Consumer Reports is a highly trusted source of information because they are completely independent of any funds from industry,” says Dr. Levinson.
Choosing Wisely Canada is using material developed by the U.S.-based Consumer Reports for its own website. “We’ve modified it, Canadianized it,” she adds. “We also translated everything into French.”
The website is meant to serve two groups – physicians and the public. For doctors, the site provides detailed recommendations from the various medical bodies. And for patients and their families, the site explains in plain language why they might not always need a test or treatment for a variety of common conditions.
So, getting back to your question about diagnosing back pain, this is one of the topics highlighted in the patient materials.
“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” says the website.
It goes on to say that an imaging test is needed only when there are certain “red flags” such as:
- A history of cancer;
- Unexplained weight loss;
- A recent infection;
- Loss of bowel or bladder control;
- Abnormal reflexes, or loss of muscle power or feeling in the legs.
But is it possible that your pain may be caused by a new, and previously undetected, cancer in the spine? That’s unlikely says Dr. Levinson. “Spinal-cord tumours are extremely rare,” she adds.
If a tumour were pressing on the nerve, you would be experiencing clearly identifiable symptoms that would have been apparent when the doctor performed a physical examination. And, as you noted in your question, your family physician found no indication of leg weakness or numbness.
The website also offers some basic advice to aid recovery and help ease the pain, such as applying heat, taking non-prescription medications and remaining physically active. (Inactivity can be counterproductive.)
If the problem persists, or new symptoms emerge, then it’s worthwhile seeing the doctor again. At the follow-up appointment, your doctor may think that it’s time for an imaging test. The campaign’s key message is that a test or therapy should not always be the first response to certain ailments.
“We want people to pause and think,” says Dr. Levinson. “Let’s reflect on it and make a good decision.”
She says some tests can be safely delayed, or avoided entirely, because there is a good understanding of the “natural history” of many common medical conditions.
In medical parlance, natural history simply means what happens to most patients when a condition is left untreated. “If you think someone has a serious illness like leukemia you don’t wait to do the test, you do it immediately, because you know from the natural history of the disease that the patient will get worse without treatment.”
Back pain, by contrast, has a very different natural history. It tends to remain the same or get better on its own over a period of time.
Choosing Wisely is reaching out to other organizations to bring them onboard. Patients Canada, a group aimed at improving patient care, has endorsed the campaign.
“We think it will help foster a more collaborative relationship between patients, family members and doctors,” says Michael Decter, chair of Patients Canada. “There should be a pretty thorough discussion with your doctor before you receive a test or treatment.”
Financial assistance and support for Choosing Wisely Canada has come from the Ontario Ministry of Health and Long-Term Care, University of Toronto, Canadian Medical Association, Canadian Institutes of Health Research and the Commonwealth Fund.
Dr. Levinson emphasizes that the main intention of the campaign is to improve patient care, rather than save the health-care system money. Even so, the initiative, if successful, should help conserve limited health-care dollars. As Mr. Dector puts it: “Inappropriate tests use up a lot of resources.”
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor
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