Less Can Be More

My patients will be interested in two studies published this week, both of which support the adage that less is more. The first, from the American Journal of Surgery, indicates that a needle biopsy should be the first diagnostic step to evaluate an abnormal mammogram instead of a more invasive surgical procedure. The other, in a position paper from The American College of Physicians, indicates that imaging studies are too frequently used to evaluate lower back pain.

An abnormal mammogram causes great concern. The good news is that in 80% of cases, there is no cancer found. When there is a malignancy, surgery is an essential part of the treatment but should not be the first line of diagnosis. A surgical biopsy means a trip to the operating room – an expensive, stressful experience. There is an increased risk of infection and bleeding. The resultant scar may be unattractive and the distortion of the underlying breast architecture makes subsequent mammograms more difficult to read.

Routinely ordering X-rays, CT scans or MRI scans for low back pain drives up health care costs and does not resolve the problem. Imaging studies are indicated if the pain worsens despite initial care or if there are signs of nerve damage or a serious medical condition (weight loss, fever or loss of sensation or muscle power in the legs). X-rays and CT scans expose patients to radiation, which over time may increase the risk of cancer.

In general, I will only order a blood test or a diagnostic procedure if we are prepared to act on the information. Curiosity is not reason enough. I particularly disdain  “shotgun medicine:” ordering every possible test to see what comes back positive. It is intellectually sloppy, a waste of someone’s money and causes unneeded stress to the patient.

More care does not mean better care. Unfortunately, it can be easier to overtreat a patient than to explain why any test or procedure has no benefit. We must always remember: primum non nocere, first do no harm.