Does it work!

In a recent issue of JAMA, there is an editorial of whether injection therapy for low back pain works. An evaluation of previous randomised trials and a meta-analysis shows that there is no clinically significant evidence that this works. And yet, we have an entire new field of pain management populated by anesthesiologists in particular but also radiologists and orthopedic surgeons, who specialise in injecting into the epidural space, facets and foramina. A cursory Pubmed review will show a large number of articles on this subject discussing technique and the value of one particular steroid over another….when in reality the efficacy of the very concept of injecting in the spine for pain management is questionable.

This is similar to the vertebroplasty controversy that still really hasn’t died, but for all practical purposes has been subverted by those who practice vertebroplasty so that the procedure can continue to be used across board.

The New York Times last week published a blog based on a recent article in the Mayo Clinic Proceedings that showed how doctors continue to use procedures and therapies that may be ineffective or may even harm patients. This is either due to ignorance or inertia, but in the period that the practice continues, harm continues to be done.

While all of us itch to “do something” each time a patient has a problem, we should constantly be asking ourselves, whether the procedures we perform and the therapies we use, actually work!

Encouraging patients to speak up

While we all have patients who are garrulous and discuss things that are completely out of context, the vast majority of patients just do not find it easy to ask all the questions that would help them with their problems. More importantly, a large number of them have no clue about the questions that they should be asking. In the end, all that people land up asking are questions like, “It is not dangerous, right?”, “What food should I eat?”, etc, which do not help either the doctor or the patient.

In a recent issue of JAMA, an article discusses this issue well. It also references a website setup by the Joint Commission that has resources that help patients with the questions that need to be asked. As professionals, we need to encourage patients to educate themselves and to be better informed – this helps us as well as the patients no end and makes for a much better relationship.

Of course, in one sense it turns around the “No turn-back” issue on its head as well, doesn’t it!


Have you followed-up this patient?

This is a post by Dr. Anisha Sawkar. You can reach her here.

The question my residents dread:  “Have you followed up on that patient?”

I work in a teaching hospital and am one of the fortunate few who have residents do a lot of my work for me. Typically, as in a lot of teaching hospitals, the residents make the first draft of a report that is then checked by the consultant. This enables teaching and hopefully, the residents learn from the changes the consultants make and the subsequent interaction that helps them separate right or wrong.

This learning will obviously be helpful but does not compare with the kind of permanent learning that will result when they follow up the patient and confirm the diagnosis that was given. Residents need to remember that we are not infallible and what we said cannot be the gospel truth. The ultimate learning will only come with the “follow-up”. The habit of following up on patients needs to be inculcated in residents during their formative years and this habit will only be practiced if they see their seniors do the same. The example will only be set if they observe that at least in difficult or ambiguous cases, their consultants go out of their way to contact the referring physician/surgeon just to find out how the patient is doing.

In a busy chaotic 2000 plus bed teaching hospital and tertiary health care center, obtaining a follow up on a patient is not always easy, and therein lies the other aspect of the story. If we maintain a close working relationship with our referring colleagues, not only will our follow-ups become easier and forthcoming; the gratification of having made a difference or the humbling occurrence of having made a mistake will help us become better at what we do. And God knows, we need to be reminded of our limitations and learn from our mistakes. As Mahatma Gandhi beautifully said “It is unwise to be too sure of one’s own wisdom. It is healthy to be reminded that the strongest might weaken and the wisest might err.”

At the resident level, these close interpersonal ties with residents of other faculties will enable a much smoother working relationship that will be of enormous help on busy on-call nights…these harmonious working relationship will ultimately benefit the patient.  Not to mention the fact that they will learn from their mistakes on call and hopefully from ours too. I’d like to end by quoting Brandon Mull who wisely said, “Smart people learn from their mistakes. But the real sharp ones learn from the mistakes of others.”

So, my dear residents, if you’re reading this, next time you’re asked for a follow up, please don’t silently curse your senior.  It is, after all, one of the best ways you’re going to learn.

Overdiagnosis – Pulmonary Thrombo-Embolism

This one is an eye-opener.

This editorial from British Medical Journal talks about the the issue of incidentalomas, which we as radiologists are aware of – lung nodules, adrenal nodules, breast lesions, etc.

What is less known is the issue of overdiagnosis. And as far the problem with pulmonary thrombo-embolism is concerned, I was quite unaware that a good number of subsegmental lesions do not need treatment, as described in this article in the same issue of the journal.

What does this mean for us? We cannot step down our ability to read thrombo-emboli. However, the treating physicians do need to make a judgement call on whether all of these patients need treatment or not.

The title of this series is “Too Much Medicine” and the article starts with the phrase “When a Test is Too Good..” All very interesting.


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