What Doctors Don’t Want You to Know

January 15, 2009
Bottom Line Personal
David H. Newman, MD

A top physician reveals why many popular treatments aren’t working

Doctors today use sophisticated tests and treatments that would have been unimaginable a generation ago. This benefits many patients, but there’s also a downside. By focusing too narrowly on technology, there’s a temptation for doctors to always do something even when they’re not entirely sure why they’re doing it — or when doing nothing might be a better choice.

The truth is, doctors guess a lot of the time. They order tests even when they don’t know what they’re looking for. They perform procedures that are unlikely to help. They give drugs that have been proven to work in general but are unlikely to help a particular patient.

What doctors don’t always admit — or don’t know…

Fact: Tests may not help. Doctors used to spend a lot of time with patients. They asked questions about their personal lives as well as their medical histories. They often could make a diagnosis before the patient left the office.

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That rarely happens today. The usual approach is to quickly order tests. Example: Several years ago, my mother went to the emergency department with severe stomach pain. Within a few hours, she was given chest and abdominal X-rays and tests for liver disease, gallstones, internal bleeding and pancreatitis.

After all that, she was diagnosed with “undifferentiated stomach pain,” a fancy way of saying that she was probably fine, but no one could figure out what had caused the pain. Did she need all of those tests? Probably not.

The tests were at least partly warranted, but doctors sometimes order tests because they don’t know what else to do. Tests should be used mainly to confirm a hypothesis, not merely to “fish” for possible problems.

Self-defense: If your doctor orders a test, ask what he/she is looking for. If the answer seems nebulous — “We’re looking for something that might explain your symptoms” — get more information. What you want to hear is something specific, such as, “I’m pretty sure you have a lung infection, but I don’t want to start treatment until I’m sure.”

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Fact: Most infections clear up without treatment. It’s estimated that at least 80% of all outpatient antibiotic prescriptions don’t help. Reason: Most infections are caused by viruses, not bacteria — and antibiotics have no effect on viruses. The vast majority of upper respiratory infections, for example, are viral. Yet half of patients who see a doctor with one of these infections are given antibiotics.

Even when patients do have a bacterial infection, such as strep throat, antibiotics may not be necessary. Infections often clear up on their own.

Antibiotics are not harmless. They kill beneficial organisms in the body that help curtail harmful microbes. Also, the unnecessary use of antibiotics may be responsible for an estimated 24,000 life-threatening allergic reactions annually.

Self-defense: If you have an infection, ask your doctor if it has to be treated. Take antibiotics only if an untreated infection — something such as bacterial pneumonia or a wound with spreading redness — is likely to cause serious complications.

Fact: Herniated discs rarely cause back pain. Magnetic resonance imaging (MRI) is the test of choice to evaluate back pain. But there’s a secret about MRIs and back pain. The most common problems physicians see on MRIs and attribute to back pain — herniated, ruptured and bulging discs — are seen almost as commonly on MRIs of healthy people without back pain. This means that herniated discs usually have nothing to do with back pain. They are a normal finding, suggesting that discs rupture with some frequency and our bodies repair them uneventfully.

Surgery to fix or remove a disc usually is performed in the hope that a herniated disc is compressing a nerve and causing the pain, but it carries a poor overall success rate. Even after the nerve is decompressed or freed by removing the disc surgically, half of the time the patient’s low back pain is not relieved.

Self-defense: Studies show that most people with back pain will improve within six months with standard medical care, such as physical therapy and the use of anti-inflammatory drugs.

Surgery should be considered mainly for patients with a herniated disc that clearly is causing a neurological deficit, such as foot weakness or a loss of bowel or bladder control, in addition to pain.

Fact: Prescription drugs may not help. There’s no question that modern medications represent some of the most important developments in medicine. Yet few doctors understand that commonly used drugs are unlikely to help certain patients.

Example: Doctors routinely recommend a daily aspirin to prevent heart attacks. This is reasonable advice for a select group of patients. Among those at high risk for heart attacks and strokes, a daily aspirin will help about one patient out of 100. The other 99 won’t benefit. This isn’t an optimal situation, but the risk for a heart attack is so serious that it is probably worth it even if 99 patients get the drug who don’t need it.

There is a statistical concept called the number needed to treat (NNT) that researchers use to measure the impact of a medication. It estimates the number of patients who have to take a particular drug in order for one person to benefit. The NNT for aspirin in high-risk patients, as described above, is about 100. The ratio for other drugs isn’t that favorable. If drugs were free and produced no side effects, the NNT wouldn’t matter, but aspirin (along with most drugs) can cause serious side effects.

Self-defense: Always ask your doctor about a drug’s NNT. A drug with a low NNT is more likely to be helpful for you than one with a high number. But always discuss the risks and benefits of a drug with your doctor.