Dr. Jon Hallberg: When is it right to do nothing?

In an era when there are numerous medical tests and procedures at the disposal of doctors, when is it the right decision to do nothing?

That's a question posed in a commentary by Dr. Lisa Rosenbaum in the current issue of the New England Journal of Medicine.

MPR medical analyst Dr. Jon Hallberg discussed the commentary and the value of "doing nothing" with MPR's Steven John on Tuesday. Hallberg is a physician in family medicine at the University of Minnesota and director of the Mill City Clinic.

An edited transcript of their conversation is below:

Steven John: Let's start out by setting up the conundrum faced by the author of this commentary.

Dr. Jon Hallberg: Dr. Lisa Rosenbaum is a cardiology fellow out in New York City. And she's an avid runner, and she injured her knee, and it got worse and worse, and she developed a small bump, and finally felt that she needed an MRI after consulting with a cousin who's an orthopedist who suggested that she need that.

And she saw her primary care physician who said, 'This looks benign. You don't really need to do anything about it. You need to rest. You need to maybe take up swimming.' And that didn't sit well with her.

John: So, ultimately what happened with her knee?

Hallberg: Well, she got the MRI, and of course, it makes the knee look absolutely horrible. She got very concerned, as did her primary care physician, which often happens. We sort of open Pandora's box. Now we know more than we wanted to know. The fact is he was right that her knee, though it looked pretty bad, didn't need surgery, that what she really needed more than anything was rest, and to do nothing.

John: How do you as a physician know that you are doing everything you can when you prescribe rest or say, 'Come back in two weeks and we'll take a look at it again?'

Hallberg: Well, I think first this speaks to the importance of having a primary care provider. If you trust your provider, whoever that may be, it's about relationship, it's about trust, it's about knowing somebody over time, and that counts for a ton. I think that the author of this article, I don't really know how well she knew her primary (care doctor), but I kind of got the sense that there wasn't a real great trust there, and that's an important piece to it.

And then the other part is 'I don't know that I'm doing the right thing.' We're basing it on experience. We're basing it on how people look. I mean that's why telemedicine and e-medicine is fine, but until you have a patient in front of you and you can actually talk to them and see them, I can tell if somebody's incredibly worried or if they clearly are in pain, and those are things that, for example, might push me to giving a scan sooner than I might otherwise do.

John: But with all of this technology, MRIs, CT scans, don't you find it tempting as a physician to use all this technology at your disposal?

Hallberg: Well, sure. It seems negligent on some levels if we don't make use of this technology, but the fact is a CT scan, for example, that's a lot of radiation that that's emitting. So you want to be thinking about that. You want to think about expense.

You want to think about what are we going to learn that is really going to impact our treatment, and I'll say that a lot of times to people. 'Look, we don't even need an X-ray because I know what's going on,' or, 'We know what's going on.' Let's treat it because it's not going to change the course of what we do.'

And then as often is the case with an MRI or a CT scan of the abdomen, let's say, you will often find some abnormality, something that you didn't really need to know, that we're not all put together exactly the same, and now we've got this little thing that has nothing to do with why you're ordering the scan, but you have to deal with it now. Or a patient sees their lab results or sees the report, and even though you want to kind of gloss over it because you know it means nothing, you have to explain that slight abnormality.

John: So, in conclusion, do you think the art of doing nothing is something that should be taught to medical students and encouraged at an early time in their career?

Hallberg: Absolutely, and I think we are doing that to some extent as best we can, but the reality is that when you are new and you're smart and you know everything, and young, newly-minted physicians and other health care providers really do, what they don't understand very well is context. And they haven't had the experience that many of us who have been practicing for a while have, and so they have to fight that temptation of ordering a test because they feel like it needs to be done.

(Interview edited and transcribed by MPR reporter Madeleine Baran)

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