Fifteen years ago I was invited to give a lecture on the island of Jamaica. One afternoon, I saw patients in the hospital with medical students and residents. It was very different from what I was used to in our university-based hospital in the United States. Many advanced imaging and blood tests were not available. To figure out what was wrong with a patient, I had to take a thorough history, do a physical exam, and carefully chose among the lab tests that were available. The experience made me question the way we practice medicine back home.
Some would argue that we perform too many unnecessary tests and procedures here in the United States, and I agree. I'm not against advanced imaging and laboratory tests—for many patients, these are necessary for diagnosis and treatment. But sometimes, more tests are ordered than are necessary. This increases cost, subjects the patient to potential complications of these tests, and can lead to unnecessary hospital admissions.
An example from my practice: sometimes a patient with Bell's palsy, which results in facial weakness caused by inflammation in the nerve supplying muscles on one side of the face, is thought to be having a stroke.
In Bell's palsy, the entire face is weak, including the muscles that raise the forehead and close the eyes. There may be pain behind the ear, decreased taste sensation, and sensitivity to loud noises on the same side as the weakness. Symptoms usually improve or completely resolve over weeks to months. Bell's palsy is treated in the emergency department or the physician's office; no tests need to be done. Current recommendations are to treat Bell's palsy, if diagnosed in the first 48 hours of symptom onset, with a short course of corticosteroids.
In contrast, with a stroke, usually only the lower half of the face is weak. Other symptoms will also be present, such as vision changes, speech problems, or weakness in the arm and leg on the same side as the facial weakness.
A patient admitted to the hospital with suspected stroke will undergo multiple imaging tests of the brain, heart, and arteries, as well as numerous blood tests. If the patient has Bell's palsy, the results of these tests will be normal, and the treatment will be the same as it would have been if the patient was not admitted to the hospital—but the cost will be about 30 times higher.
It goes without saying that we would never want to mistake a stroke for Bell's palsy. And facial droop is one of the warning signs of stroke, so we expect people to be concerned and come to the emergency department immediately or call 911 if they develop any facial droop. It is the physician's job to determine if a patient with a facial droop has Bell's palsy or a stroke and order the appropriate tests and treatment.
This example is not an isolated case. In this issue of Neurology Now, we talk about the Choosing Wisely program (see page 23), designed to reduce money wasted on unnecessary medical services ($750 billion in 2009 alone!). Money spent on unnecessary medical services does nothing to improve human health. The American Academy of Neurology has joined other organizations in identifying five tests or procedures commonly used in our field that don't have strong evidence to support their use. Physicians need to carefully consider which tests are really necessary and which are not, by taking into consideration the best interests of each individual patient and the best medical evidence. Patients and caregivers need to discuss diagnosis and treatment plans with their physician and be sure they understand why tests are being ordered, why treatments are being recommended, and how likely they are to be of benefit. This will lead to the best medical care for all of us.
Take good care,
Robin L. Brey, M.D.