Jennifer Yttri, PhD
When you walk into the doctor’s office, your first thought might not be “what questions should I ask my doctor,” but maybe it should be. Not every test or procedure is appropriate for every patient and many are over-used. What is beneficial for one person isn’t worth the risks for another. Often the best health decisions can be made when physicians take the time to talk with their patients.
Consumer Reports and the ABIM Foundation are working with medical specialty societies to create lists of “5 Things Physicians and Patients Should Question” as part of a national campaign called Choosing Wisely (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists are recommendations made by experts based on scientific evidence. Here is their list of tests that are given too often, including recommendations about when they are most likely to be useful or necessary.
CT scans are not recommended for patients with abdominal pain unless the results will change the course of treatment. CT scans of the abdomen expose patients to one of the highest levels of radiation from medical tests, equivalent to hundreds of chest x-rays or 3 years of background radiation. Unless the test is in response to major changes in symptoms and can lead to differences in treatment, CT scans are not worth the increased cancer risk from radiation.
Skin or blood tests for allergies should only be used if a patient has allergic symptoms that are not controlled by over-the-counter medications or if a doctor suspects an allergy. Allergy tests are costly and can detect allergic responses that may never happen in real life. Allergy tests should not be used to figure out why someone has chronic hives, as those do not normally result from allergies.
Asthma should not be treated or diagnosed without measuring lung function. Lung function can be tested with spirometry. This simple breathing test is much better at diagnosing asthma than having a patient provide a history of symptoms or doing a physical exam. Diagnosis without spirometry can lead to prescribing asthma medication to people who don’t have asthma. Spirometry testing should be done a few months after starting treatment and at least once every two years.
Autoantibody testing (ANA testing)
ANA testing is often performed to detect autoimmune diseases or immune system disorders, like multiple sclerosis or lupus. If a patient is negative for ANA (anti-nuclear or autoantibodies), further testing of antibodies is not recommended. If a patient is positive for ANAs, further testing should be based on disease symptoms which can help a doctor predict what specific types of antibodies to test for. This strategy reduces unnecessary testing.
Patients diagnosed with Barrett’s esophagus as a consequence of gastroesophageal reflux disease (GERD) should get their esophagus lining examined for signs of abnormal cells once every 3 years. These cellular changes, which can result in a type of cancer called adenocarcinoma, take a long time to develop and therefore more frequent screening is not recommended, especially in younger patients.
Small, simple cysts are common in women and usually won’t affect their health. If one is found, the doctor will schedule an ultrasound to determine if the cyst is benign (not cancer). If the cyst is not cancerous, a follow up ultrasound and surgery is not recommended unless the cyst causes symptoms, like pelvic pain. If the cyst is suspected to be cancerous, a follow up ultrasound is not recommended because the cyst should just be surgically removed. A second ultrasound is only recommended for larger cysts that the doctor could not be sure about.
Enlarged Prostate or benign prostatic hyperplasia (BPH)
As men age, it’s common for their prostate to become enlarged, a condition called benign prostatic hyperplasia or BPH. Usually BPH does not cause problems until men are near age 60. If patients are having problems urinating with limited or no other symptoms, evaluation beyond the standard prostate exam is not recommended. Patients are unlikely to have problems in the future due to their current condition. Should symptoms change, follow up tests, such as ultrasound, biopsy, or cystoscopy, may be useful for deciding on treatment.
Bleeding time test
The bleeding time test was designed to measure how long it takes for a patient’s blood to clot. This is an old, unreliable test that also leaves a forearm scar. The bleeding time test has been replaced with a coagulation test that more accurately predicts a patient’s risk of bleeding during surgery. Therefore, the bleeding time test should no longer be performed.
Blood drawing for testing
Frequent blood draws can cause anemia. Repeated blood draws for testing of hospitalized patients is not recommended if there is no change in symptoms or test results.
Breast cancer screening
Breast cancer screening is done through mammograms, which are like x-rays. A breast cancer diagnosis involves giving the cancer a stage (0 through 4, with 4 being the most advanced) based on the size of the tumor, how advanced it is, and how likely it is to spread. Other imaging tests, like PET, CT, and bone scans are not recommended for screening early stage breast cancer (stages 0-3), patients newly diagnosed with Ductal Carcinoma In Situ (DCIS), or people without symptoms. This testing does not benefit patients, and false-positives (test results that indicate cancer when no cancer is present) can lead to unnecessary procedures and misdiagnosis. For anyone who has been treated for early-stage breast cancer and is symptom free, mammograms and regular clinical exams are the best ways to check that the cancer has not come back. Advanced imaging tests and tumor marker tests should only be used for patients with later-stage breast cancer.
Bronchiolitis and respiratory infections in children
Respiratory tract infections are common in children. Chest x-rays, used to diagnose some respiratory infections like TB, are not recommended for diagnosing bronchiolitis or common childhood respiratory infections. Physical exams and patient history are much more reliable ways to diagnose these. Chest x-rays should not be used to diagnose a child with asthma-like symptoms (see asthma above).
There are many tests to measure heart function and screen for heart disease. Usually these tests fall into two categories: tests performed while at rest, which measure normal function, or tests performed when the heart is working hard (under stress), such as after exercise. Electrocardiogram (EKG), radionucleotide imaging, echocardiogram, CT, and other cardiac screening, either resting or stressed, are not recommended for patients without symptoms or who are at low risk for developing heart disease. These tests are often inaccurate at diagnosing minor or moderate heart disease. Imaging tests often provide misleading information when used as a wellness test or as part of routine follow up testing for patients who do not have changes in their symptoms. These tests are also not recommended for assessment prior to low or medium-risk non-cardiac surgery or before and after surgery for patients who have no history or symptoms of heart disease. Such screening is more likely to result in false positives (results that indicate heart problems when the patient doesn’t really have any) and unnecessary procedures than to detect problems or change medical care. Patients with risk factors or a history of heart disease, or with symptoms related to heart disease, should get resting tests and possible stress tests. Imaging tests are recommended five years after bypass surgery or two years after a stent procedure.
Cervical cancer screening
Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. Women under 30 should not have HPV tests to screen for cervical cancer. Women with mild dysplasia or cervical intraepithelial neoplasia (CIN1) for less than two years should not be treated for cervical cancer, as CIN1 is usually caused by a short-term HPV infection and goes away within a year. Pap smears (see below) should be used to screen for cervical cancer.
Patients without signs or symptoms of heart or lung disease do not need a chest x-ray before surgery. Chest x-rays are not costly but they do expose patients to a small amount of radiation and can lead to expensive follow-up tests if a problem is detected. Chest x-rays are recommended before surgery for anyone having heart, lung or chest surgery and for patients over 70.
Children with Febrile Seizures
Febrile seizures happen when children have a high fever. Doctors should try to identify the cause of the fever when treating infants or children who have had a febrile seizure. CT and MRI scans of the brain are not recommended for children who have had a febrile seizure. CT scans use radiation and exposing children to radiation can increase their risk of developing cancer. MRI scans are very costly and require sedation, which exposes children to unnecessary risks.
Colon cancer screening
For people who are at an average risk for developing colon cancer, tests such as stool tests and sigmoidoscopy can be used instead of colonoscopy to screen for colon cancer. Abnormal results from these tests require follow-up with a colonoscopy. The plasma test named methylated Septin 9 (SEPT9) is an alternative screening test but it is not recommended unless the more conventional tests and colonoscopy are not feasible.
Screening colonoscopies are recommended, starting at age 50, every 10 years for adults at low risk. Colonoscopies may be done more frequently if a polyp (growth in the colon) was found and removed in a previous colonocopsy. Colonoscopies are very good at detecting small, low-risk polyps (less than 1 cm) that grow slowly. More frequent screening is not recommended because colonoscopies and polyp removal are expensive and risky. For patients who have had larger polyps removed and need more monitoring, colonoscopies should be performed more than once every 5 years. Routine checks are not needed after age 75.
Continuous telemetry monitoring of cardiac function
Sometimes hospitals will attach a device to a patient so they can move around and still have constant monitoring of their heart function. This telemetric monitoring is not recommended if patients have a normal electrocardiogram and are at low risk for cardiac problems.
Coronary artery calcium scoring
The level of calcium in coronary arteries can predict coronary artery disease. Calcium is found in plaque that builds up in and blocks arteries. Calcium levels in arteries in the heart are measured by computed tomography (CT) scans. However, coronary calcium scans are not recommended for diagnosing or evaluating development of coronary artery disease in patients without symptoms, family history, or those who enter the ER with chest pain. Calcium scoring is not recommended as a preoperative test or for individuals who already have stents and bypass grafts as it will not provide new information that can change treatment.
Ultrasound is not recommended for boys with cryptorchidism, a condition where the testes do not descend into the scrotum. A physical exam is more effective at locating testes.
CT scans in children
Computed tomography or CT scans use radiation for imaging. Exposing children to radiation is especially risky for increasing their lifetime risk of cancer because their tissues are sensitive to radiation. CT test are not recommended for children who are being treated for minor head injuries, febrile seizure, or abdominal pain including appendicitis.
Deep vein thrombosis (DVT)
DVT is very common. However, lab tests to detect a clotting disorder like DVT are not recommended as the results will not alter treatment of a venous blood clot. An ultrasound to evaluate how a patient is responding to therapy is also not recommended because the result will not change the treatment.
Dementia and Alzheimer’s disease
Memory loss is a natural consequence of aging. Memory loss alone, however, is not a reason to get tested for dementia or Alzheimer’s. A PET scan takes an image of the brain looking for plaques that are associated with Alzheimer’s. However, imaging is not recommended for evaluating dementia or reasons for memory loss. Plaques on a PET image do not mean you have Alzheimer’s and a lack of plaques does not mean you won’t develop it in the future. Instead, have a doctor who specializes in dementia and Alzheimer’s give you a medical evaluation first.
Imaging tests are not recommended for patients who do not show signs of significant eye disease. A patient’s history and a physical examination by an eye doctor are all that are needed to detect eye disease or see if it is getting worse.
When a patient goes in for a complicated surgery, they may be given a battery of tests before the surgery takes place. Eye surgeries are usually short and uncomplicated. Therefore, these preoperative tests are not recommended for eye surgeries unless a patient has a pre-existing condition that justifies a test.
Fainting will happen to 40% of people during their lifetime. Unless a patient has other neurologic symptoms, imaging of the carotid arteries to identify a reason for fainting is not recommended because a block in the arteries does not cause fainting. The cause will remain unknown after the expensive test.
Heart valve disease
Valve disease can be very serious and should be monitored. However, if the disease is mild and not causing symptoms, echocardiograms, a simple ultrasound of the heart, are not recommended. Mild valve disease doesn’t usually cause problems. Echocardiograms are recommended if a heart murmur is strong, gets worse, or symptoms develop. Tests should also be used if a valve has been replaced.
Migraines are painful and can last a long time. Doctors may want to diagnose headaches using CT or MRI imaging. This is not recommended as it is costly and is no better than clinical evaluation. Imaging should only be done if a doctor can’t confidently diagnose headaches based on symptoms and a neurologic exam or if the exam has an abnormal result.
Skin and blood testing for allergies are not recommended for patients with chronic hives, hives that last for weeks. The tests are costly and may not help determine an underlying cause as chronic hives are rarely related to allergies.
Patients suffering from hoarseness should have their larynx examined by a doctor. If there is evidence of damage or a lesion, CT or MRI scans can be used. Because of the high costs and potential radiation exposure, CT or MRI scan should not be done without a doctor’s examination first.
HPV testing is not recommended for low risk infections, such as for HPV associated with genital warts. HPV testing should be used to identify high risk infections in patients with abnormal Pap smears or other clinical symptoms associated with high risk HPV infections.
Lower back pain
Patients experiencing lower back pain should not have imaging tests, such as MRI, X-ray, or CT scans, to diagnose pain. These tests are costly, expose patients to radiation, and don’t help patients get better faster. Imaging tests are useful if patients have signs of severe nerve damage, have serious underlying problems like cancer and spinal infection, or if symptoms don’t improve in a few weeks.
Patients suffering from arthralgias, myalgias or fibromyalgia should not be tested for Lyme disease unless they have other symptoms of Lyme disease, such as a bulls-eye rash, and reason to believe they have been exposed through a tick bite. Also, Lyme disease tests have a high rate of false positives (results that indicate a person has Lyme when he or she doesn’t) so patients who may have been exposed to Lyme disease should be examined by a qualified doctor for signs and symptoms before being tested.
Monitoring oxygen during respiratory illness
Pulse oximetry measures oxygen levels in the blood through a sensor. It is important for situations where blood oxygen levels need to be monitored or can change rapidly, like during surgery, in emergency or intensive care, or when on oxygen support. Continuous pulse oximetry is not recommended for monitoring children with respiratory illnesses unless they are on support oxygen.
DEXA (dual energy x-ray absorption) is an expensive bone-density screening test. While DEXA can detect osteoporosis, many people will only learn that they have mild bone loss and will still be put on risky drugs without proven benefits. DEXA is not recommended for women under 65 or men under 70 unless they have a history of risk factors for weak bones. Healthy men (over 70) and women (over 65) can be screened every 10 years as long as their risk factors do not change.
Ovarian cancer screening
Women at average risk who do not have symptoms should not be screened for ovarian cancer. Screening using ultrasound or blood serum testing might detect early signs of cancer, but ovarian cancer is uncommon in women of average risk without symptoms. An abnormal result that isn’t cancer might require invasive follow-up, and those risks outweigh the benefit of early detection.
Pap smears detect cervical cancer. They are not recommended for women under 21. They also are not recommended for women who have had their cervix removed during a hysterectomy and have no history of cancer. Most abnormalities in young women go away without treatment. For women who have had a hysterectomy for reasons unrelated to cancer, Pap smears do not provide any useful information. Pap smears are recommended every 3 years for women aged 21-65. Women over 65 who have had normal Pap tests can stop having them done.
Preoperative testing for low risk surgeries
Preoperative tests, like measuring blood count or glucose levels, are not recommended for healthy or clinically stable patients. Test results rarely influence a low-risk, elective surgery procedure or have any effect on patient recovery. Patients who have symptoms or risk factors that may complicate surgery should get appropriate preoperative diagnostic testing.
Prostate cancer screening
Gleason and PSA tests are used to measure how aggressive prostate cancer is and how likely it will spread. Imaging tests can then be performed to identify exactly where cancer has spread. These imaging tests, such as bone scans, PET, and CT, are not recommended for detecting disease in men who are newly diagnosed with low-grade prostate cancer. Imaging tests are expensive, can expose men to high levels of radiation, and are unlikely to provide more information about early prostate cancer. Only men with Gleason scores above 7 and PSA levels above 10 nanograms/mL should consider imaging tests.
CT scan is not recommended for diagnosing a pulmonary embolism in young women. Instead a radionuclide ventilation/perfusion (V/Q) imaging study should be used, because it can detect a pulmonary embolism with a lower dose of radiation to the breast.
Rheumatoid Arthritis (RA)
MRI is not recommended for diagnosing or monitoring RA. While there are cases where an MRI may provide more information than other methods of assessment, it is not cost-effective in comparison to physical exams, lab tests, and x-rays, and therefore is not recommended as general practice.
Sinusitis is diagnosed based on symptoms (e.g., nasal drainage, pressure, and nasal blockage) and is usually related to allergies or the common cold. Some doctors will want to order a CT scan of nasal passages but this is unnecessary for diagnosis.
Stage 1 non-small cell lung cancer (NSCLC)
Lung cancer is the most common type of cancer to spread to the brain. However, the chance of patients with early, stage 1 lung cancer developing brain metastasis is very low. Because the rate of false positives (results indicating that disease is present when it isn’t) is much higher than the actual rate of brain metastasis, brain imaging by MRI or CT is not recommended for patients with stage 1 NSCLC unless they have neurologic symptoms.
Sudden hearing loss
CT scans are not recommended for patients suffering from sudden hearing loss. CT scans should only be used for patients with a history of trauma, chronic ear infection, or neurologic symptoms.
Radioactive iodine is absorbed by the thyroid and can be used to give doctors a picture of what the thyroid looks like, how it is functioning, and if there are any nodules in the area. Imaging with radioactive iodine is not recommended for determining whether thyroid nodules are benign or cancerous unless the patient is hyperthyroid. Nodules should be biopsied if the thyroid functions normally.
Venous thromboembolism (VTE) and Pulmonary Embolism (PE) screening
Patients with a low probability of VTE and PE should be initially diagnosed using a D-dimer measurement. This test is highly sensitive and if the results are negative (nothing suspicious found), there is no need for more costly imaging tests.
Routine lab testing for vitamin D is not recommended as vitamin D deficiency is common in many people, like those living at high altitudes, those with little sun exposure, and also to some extent during winter months. Vitamin D deficiency is easily fixed with over-the-counter supplements and by being in the sun.