Too many tests

Monday, August 25, 2014

In our mind’s eye, we could all throw it like Peyton, hit like big Papi and be like Mike. But while we aspire to their greatness, we should not ask to have their medical testing inflicted upon us. Today’s elite athletes can no longer be content with medical opinion, rather they or their team management expect that the latest technology be used to help make the diagnosis.

The latest victim of this syndrome is Carolina Panther quarterback, Cam Newton, whose rib injury during a preseason game might have been diagnosed with a brief history and physical examination. Mere mortals might have needed a plain chest x-ray but Mr. Newton also got a CT and MRI of his chest. The verdict? He had a nondisplaced rib fracture. And how did those extra tests affect his care and treatment? They didn’t.

Medicine has gone high tech with imaging tests that can peer inside every nook and cranny of the body to find things that may or may not matter. Chest wall injuries area prime example of what if gone wild. The ribs and muscles that make up the chest wall serve a couple of purposes. Most importantly, they act as a bellows, swinging up and out to suck air into our lungs to help us breathe and then again squeezing back in to make us exhale. It doesn’t matter if a rib is bruised or broken, the pain of either injury makes it difficult to take a deep breath and that interrupts the mechanism of breathing. When the lung does not adequately expand with inspiration, the patient runs the risk of getting pneumonia, an infection of the lung, and that is the great complication of a rib injury. The ribs also protect those organs that are located beneath. The lungs are obvious but the lower ribs also protect the spleen and liver in the abdomen and lower chest trauma can cause damage to the upper abdomen.

This is where the art of medicine comes in. Taking a history allows the doctor or other care provider to understand how much force was inflicted upon the patient and understanding the patient appreciates how much force they can withstand. A frail elderly patient who falls against a countertop and injures ribs is perhaps more likely to have underlying damage than a padded quarterback being hit by a linebacker. The physical examination can help decide whether a small area of the rib cage is damaged or whether numerous ribs are injured. The larger the injured area, the more likely that the breathing mechanism is compromised and the potential for complication increases. For most patients, a plain chest x-ray is adequate to look not for rib fractures but for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Ordering rib x-rays to look for a fracture is a waste of time, money and radiation. Physical exam will also tell you whether there is enough abdominal tenderness to us CT to look for internal bleeding.

But the art of medicine is not infallible and perhaps that is feeds the fear of missing an injury. Green Bay Packer center TJ Tretter hurt his knee early in the game against Oakland but played on after doctors evaluated him on the sideline and cleared him. Unfortunately, he had a fracture that will sideline him for the next many weeks. The same fear also feeds the use of CT to routinely evaluate concussions when there are clinical guidelines that can help decide who needs a scan and who doesn’t.

One can appreciate the high medical tech approach to those athletes whose salaries run into the tens millions of dollars and those teams who market the player to their maximum advantage, yet the general population takes their cue from what they see on the field, on the sideline and in the training room. Ideally, regular folk should ask the doctor why a test is being ordered and what benefit it will bring. Sometimes, tests are ordered just because with little thought. Other times, the decision as to what test to perform takes great thought. Sometimes, there is risk management involved. The doctor doesn’t want to miss a diagnosis, not only for the patient’s sake but also for fear of being sued. In many situations, if the patient were asked, they might agree the risk of missing the diagnosis was not enough to perform an expensive or painful test.

This shared risk happens routinely when a diagnosis has been made and treatment options are being contemplated. The patient often helps decide if they want aggressive or more conservative treatment options or perhaps an operation now or later. There is no reason that the process of involving the patient cannot happen earlier in the diagnosis phase as well. The key is communication is to allow the patient to become a partner in the all decision making process and not the object of it.

For Mr. Newton, his ribs are going to hurt for the next few weeks, regardless of whether they are broken or bruised. It will hurt to take a deep breath or to twist to throw or hand off the ball. It won’t matter that it took a CT scan or MRI to make the diagnosis of the broken rib. A good physical exam might have been enough, but it wouldn’t have been perfect…but even the best rarely are.

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