Ask Dr. Hallberg: The 5 routine procedures for doctors to avoidby Dr. Jon Hallberg, Minnesota Public Radio,
Tom Crann, Minnesota Public Radio
St. Paul, Minn. — Less is more. That's the message from a new program by the National Physicians Alliance. The nonprofit group is urging primary care doctors to avoid five common medical interventions, arguing that the procedures are both costly and unnecessary.
MPR medical analyst Jon Hallberg discussed the recommendations this week with All Things Considered host Tom Crann. Hallberg is a physician in family medicine at the University of Minnesota and director of the Mill City Clinic.
Tom Crann: First off, what are we talking about? Why were these guidelines, if we can call them that, actually issued?
Dr. Jon Hallberg: Well, this sort of sprang from a couple of things. One is that the American Board of Internal Medicine is really looking at some professionalism issues, and they feel that one of those issues stems from wasting money, wasting billions of health care dollars. And then there was an editorial that appeared in the New England Journal of Medicine. And so these two factors kind of led to this group, the National Physicians Alliance, to come up with a list of five things that we could do in these three primary care specialties that could really save billions of health care dollars.
Crann: So let's go through them now. The first one: Don't do imaging for low back pain right away. Why not?
Hallberg: Well, a lot of people will come into a doctor's office (for low back pain). In fact, they found that low back pain is the fifth most common reason that people will see physicians. So the temptation many times is to get an x-ray, get two views, one sort of a straight-on view, one a side view. But the fact is that there's almost never anything there that's really something we can do anything about. So you're exposing people to some minimal radiation. You're accruing costs that probably don't need to occur, and honestly, we usually tell people early on if they don't have neurologic symptoms to take some anti-inflammatories, to rest, to do some stretching, that kind of stuff.
Crann: And give it some time, after a certain point, though, you would do the imaging.
Hallberg: Oh, certainly. If it's been six weeks and the pain has not improved and it's severe or there's some neurologic symptoms, pain shooting down legs, for example, well, then of course we'll go ahead and get the x-ray.
Crann: What about routinely prescribing antibiotics for sinus infections, sinusitis? This also is another don't.
Hallberg: There was a study a number of years ago that came out that did CAT scans in people who had bad colds. And almost everybody on the CAT scan had what looked like a sinus infection. Eighty percent of the time when people present with a possible sinus infection, they leave the office with a prescription for antibiotics, and most of this is just completely unnecessary.
Crann: And it doesn't help?
Hallberg: It doesn't help. I mean it'll run its course. It seems like it's helping, of course, because you've got this and in a few days you're better, but if you had just waited, you would've been better, too. And these days I'm finding that even the ear, nose, throat doctors are recommending that people try things like nasal irrigation or neti pots to get things cleared up at first.
Crann: No annual electrocardiograms or ECGs, why not there?
Hallberg: Well, this is not really part of my generation. Many people would go to their internist or family physician for an annual physical and they'd get a chest x-ray and an EKG and a bunch of laboratory tests as just routine, as standard of care, but there's not a lot to be gained.
In fact, there's a lot of harm that might come from that because very subtle changes on the EKG often increase anxiety and (lead people to) ask for further testing that ultimately is unnecessary. We should be much more focused on cholesterol levels, blood pressure, blood sugar or diabetes status, that kind of thing.
Crann: What about no pap smears for women under 21?
Hallberg: This might be a little bit surprising, but they're finding now that a lot of young women below the age of 21 who have some dysplasia or some changes to the cells from a pap smear under the microscope often resolve spontaneously. It doesn't need any further workup.
Crann: Then there's number five. Don't use DEXA or bone density screening for osteoporosis for women under 65 and men under 70.
Hallberg: This is another one I think that's a little surprising to a lot of us in primary care because I know we've been ordering these scans on people younger than that. Many times when women reach the age of menopause, on average, age 50 or so, it's been very common to go ahead and get a bone density scan. So there are two (exceptions). They're saying unless people have had fractures under the age of 50, for example, or we know that they have some calcium or vitamin D deficiencies, then there are reasons to do it, but for the most part, we should really wait and do those when people are older.
Crann: Now I noticed there's a top five list as well for internal medicine. Three are the same, but two are different. Why?
Hallberg: Well, the first one is not obtaining routine blood chemistry panels or urine tests. Again, this has been very, very common when people come in. We just get a metabolic panel. We're looking at their electrolytes and kidney function tests. And they're basically saying, look, unless people have high blood pressure or diabetes or some reason that we need to get that, just doing it routinely doesn't tell us anything really.
Crann: Would you need it for a new patient, though, as a baseline?
Hallberg: No, we really don't. It depends on the age of the patient. I mean everything really should be personalized, and so if someone does have high blood pressure, of course I really want to know what their kidney function is like. I might be putting them on a blood pressure medication that could lower or raise their potassium level. I want to know that, but then there's a reason for that. It's not just because.
Crann: Is this just a matter of saving money?
Hallberg: It's not just about that, but of course we can't ignore that. If we follow these guidelines, we're saving billions of dollars. And when resources are tight, we have to be thinking that way, but I also think that this really is about practicing good medicine. This is all based on evidence-based medicine. This is not hunch. It's not intuition. It's based on what the facts show, and most of us try as hard as we possibly can to practice medicine like this. It isn't always possible, and we can't always get there, and in fact I know no physician who can succeed in all of these areas all the time, but if we even tried, we would save a lot of money, and we'd be practicing better medicine.
(Interview edited and transcribed by MPR reporter Madeleine Baran)
- All Things Considered, 06/09/2011, 4:50 p.m.
Assistant professor in family medicine at the University of Minnesota, and medical director at Mill City Clinic.