By Randi Sokol
Patients generally come to the doctor’s office expecting that their doctor will do stuff. And, doctors often feel a sense of satisfaction the more they can do for their patients. Psychologically, it makes sense: as doctors, we feel a sense of purpose by providing, measuring, injecting, prescribing, cutting, and ordering. We want to help set our patients down a healthier pathway, which often requires change in their current status; naturally, we respond to this call to duty to promote change by doing, doing, doing. But is all this doing really necessary?
The mentality to do permeates all areas of medicine, regardless of whether evidence supports the utility and outcomes of such efforts:
Monitoring pregnant women in labor is a classic example of doctors’ desire to do something despite evidence-based guidelines. When a woman is admitted to Labor & Delivery Ward of hospital, an external fetal monitor (EFM) is placed on her belly to monitor her baby’s heart rate and make sure that the baby is getting enough oxygen. Should the monitor reveal the baby’s oxygenation is compromised, the woman might get rushed to a c-section. As physicians on the L&D wards, we spend countless hours of our day following and reading all our laboring women’s fetal heart monitors. We have computer displays set up in our break rooms, in our board room, and displays all over the floor with nurses and physicians watching the monitor at all hours. But is this really even necessary?
Use of the EFM became popular in the 1960s and 1970s to help physicians diagnose when fetal distress was occurring to prevent neurological damage. But, there is another option: instead of placing the pregnant mom on an external monitor, she can have periodic evaluations of her baby’s heart rate- deemed intermittent auscultation. Now which method is best for mom and baby? Neurological abnormalities are actually not caused by intermittent asphyxia during delivery, and numerous studies have documented that fetal outcomes are the same regardless of which method is used: there are no differences in fetal mortality, Apgar scores (which predict how healthy the baby will be), or the need to place the baby in the intensive care unit between the two monitoring methods. And, EFM has been shown to increase the number of c-sections. This means mom might have an unnecessary and very invasive operation, the baby is not born naturally, and there is possible delay in opportunities to breastfeed and bond.
The US Preventive Services Task Force, which makes recommendations about how physicians should practice based on sound evidence, even states that there is “fair” evidence that “routine EFM for low-risk women in labor is not recommended.”3 For high-risk women, the Task Force states, “There is insufficient evidence to recommend for or against EFM.”
Yet, as physicians, we center our care around the EFM- it seems bizarre, doesn’t it? If training were different and more physicians and nurses were taught how to do intermittent auscultation, we could take a much more hands-off approach to patient care that might actually produce better health outcomes in the long-run. Granted, a change in practice comes with numerous obstacles: legal, financial, educational, and technical. Because this practice has been in place for several decades, physicians would likely be more vulnerable to malpractice lawsuits if they stopped using EFM despite being trained in intermittent auscultation. And, intermittent auscultation would require increased staffing of nurses, which of course requires increased funding. Clearly, this issue is not so black and white. Yet ,we continue to engage in a practice that evidence does not support as the drive to do, to assess, to monitor, to act persists.
The Newborn Nursery world is also not immune from the mentality that more is better. One of the lab values that pediatricians carefully monitor is the amount of bilirubin, a pigment that a newborn has in their blood– the great fear being that too much bilirubin can cause neurological damage (a condition known as kernicturus or bilirubin encephalopathy). As physicians, we thus monitor bilirubin levels carefully, which often requires drawing blood from the baby and even placing the baby under special lighting that helps remove the bilirubin. The time receiving phototherapy means less time bonding with mom, compromise of breast feeding, and infant weight loss.
Yet, the evidence does not support this practice. According to the U.S. Preventive Services Task Force, ‘the evidence is insufficient to recommend screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy.’ In fact, infants that develop bilirubin encephalopathy can have NORMAL levels of bilirubin. There is actually no known screening test that will reliably identify all infants who are at risk of developing bilirubin encephalopathy. And, its incidence is so rare (occurring in as few as 0.9 individuals per 100,000 live births), is it really worthwhile to screen? Do the benefits of catching that 1 individual in 100,000 live births outweigh the risks of subjecting infants to unnecessary blood draws, worrying mom and dad when levels are high, subjecting infants to phototherapy and exchange transfusions, removing the infant from maternal bonding time, not to mention the cost to the medical system and the time physicians spend measuring and analyzing bilirubin levels? While we like to be pro-active in our management of a newborn life and give infants the best possible beginning, our intentions are certainly respectable, but are the ultimate outcomes equally worthwhile?
Even preventive efforts that encourage more labs and do more evaluations are often not evidence-based. For example, beginning at the age of 50, it is common to screen men for prostate cancer. So, should all physicians be ordering a lab (called PSA) that can assess for early prostate cancer? For men at high risk, this makes more sense: African American men, men with a brother or a father who had prostate cancer, and men with female relatives who have a specific type of breast cancer (with the BRCA gene) are at increased risk for prostate cancer; obviously the best chance for curing prostate cancer is by finding it in an early state and then treating it with radiation or surgery; and finding it early means it is more likely to be confined to the prostate gland and has not spread to other areas of the body (which would make it much less treatable).
However, for many men (without risk factors), a PSA can be falsely positive- which leads to unnecessary worry and unnecessary biopsy procedures and even unnecessary treatments. In fact, one study showed that 75% of men with an elevated abnormal PSA who had a subsequent biopsy did not have prostate cancer. Additionally other studies have shown that prostate cancer screening did not reduce that chance of dying from prostate cancer. Additionally, men who are diagnosed with prostate cancer (from PSA and then biopsy) often do not die from prostate cancer- prostate cancer often grows so slowly that men will die of other causes before they even begin to develop symptoms related to prostate cancer. And, not all prostate cancer kills (and thus does not warrant treatment), yet many men will suffer the side effects of treatment from a cancer that would otherwise not kill them.
Thus, as physicians, we should see our role as providers of information- laying down the risks and benefits of screening and allowing our patients to decide if they do or do not want to be screened. Based on their personal experiences and backgrounds (which we may not be privy to), patients often have their own reasons for wanting or not wanting particular things done. Still, the same notion rings true: doing is not necessarily in the patient’s best interest and physician providers must remain vigilantly conscious of this.
And one final example because it is just so common:
One of the most common complaints in an outpatient setting is back pain. The reality is that most back pain (unless it is something very serious like cancer, an infection, or cauda equina syndrome) gets better by its own after 6 weeks.
The “Six week rule” has been proven: no matter who provides care to the patient (private PCPs, HMO PCPs, chiropractors, or orthopedic surgeons), at six weeks after initial presentation, most patients improve and have the same degree of very minimal functional impairment. Yet, at initial evaluation of back pain, the tendency is to evaluate as much as possible, and often times patients even come in requesting X-rays or MRIs. Yet, the utility of imaging at initial presentation is poor and often can be to the patient’s own detriment. Studies have shown that many patients without symptoms have abnormal imaging studies.
And many with back pain will have abnormal studies, but most of these findings will be unrelated to the patient’s symptoms and might thus provoke an unnecessary surgery that ultimately does not resolve the back pain. In fact, the mantra of the “One-third Rule” holds true for back surgery: One-third of patients will get better, one-third will feel no change, and one-third will actually get worse. And, then there is the cost, time, and patient distress associated with all these actions. The bottom line is that most patients will naturally improve on their own, and back pain is often best managed conservatively with minimal testing and minimal doing.
Obviously patients come to doctors for a reason. As physicians, we have the knowledge and experience that makes our clinical judgment valuable in helping our patients achieve optimal health. But, with that knowledge and experience, we must remember that doing more is not always better.
Often times, simple listening, reassurance, and equipping our patients with information is all that is needed. We must be cautious in our tendencies to order more images, perform more procedures, track more labs, and prescribe more medications. We must change our patients’ expectation of what we are willing to do so that they understand that our intentions are well-meaning and follow evidence- based practice. Explaining the risks and benefits of subsequent management options to our patients and why we recommend for or against a certain approach empowers them with the knowledge and rationale for moving forward, inspiring collaborative decision making between patient and provider.
Thus, while it might seem counterintuitive to do less, this approach will ultimately benefit our patients more. And, by engaging our patients in this decision-making process, their care truly becomes patient-centered.
Randi Sokol is a Second Year Resident in the Department of Family & Community Medicine at UC-Davis. The views expressed in this article are her own and do no represent those of UC-Davis.