Blog | Wednesday, July 11, 2012

Less is more in lower back pain (now tell the patient that)


Often, doctors and patients request unneeded tests out of either ignorance, inertia or fear. Recently, I was part of the Good Stewardship Working Group of the National Physicians Alliance, which convened focus groups of different medical specialties to agree on "Top 5" lists of procedures or tests which are medically contraindicated and can cause harm. This work was published in the Archives of Internal Medicine.

As a continuation to that work, we recently published a review in Archives summarizing the reasons why requesting imaging (i.e., X-rays, CT scans, or MRIs) in routine cases of lower back pain without red flags is not a good idea, and quantifying the harm to the patient. Read it here.

Of course, the question outside the scope of the immediate article is this: what happens when the patient, against all recommendation, wants one of these imaging modalities anyway? Should the doctor do it or not?

This question attracts me because it makes things complicated. The interest of the patient comes into conflict with our interest. Do we respect the patient's statement as it stands, do we encourage the development of a more knowledgeable approach to medical testing, or do we avoid the conversation with some appeal to insurance companies' coverage criteria?

In a useful review in JAMA, Brett et al. say, "Actively challenging patients' requests for nonbeneficial interventions does not subvert properly understood respect for patient autonomy and is consistent with the professional obligation to practice high-quality, cost-effective medicine."

This is true enough. Challenging never subverts autonomy. But decision-making does. So what do we do when the rubber meets the road?

It's not an easy question. What would you do in such a conflict, as doctor or patient?

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.