Are your doctors basing your care on the strongest scientific research? We asked medical experts to point out some of the most worrisome ways doctors are falling short—and occasionally, even making mistakes.
1. High Blood Pressure
The blood pressure mistake your doctor may be making: Sticking with lifestyle changes when you need drugs.
The evidence shows that it’s safe to try to bring down mildly elevated blood pressure by eating better and exercising. But if your numbers are even moderately high, the advice is unequivocal: Your doctor must prescribe drugs because uncontrolled high blood pressure puts you at risk for a deadly heart attack or stroke.
Guidelines making this clear were crafted by a panel of leading scientists in 2003. But when 22 community doctors were asked by University of Texas researchers how they’d treat a hypothetical middle-aged man with the moderately high blood pressure of 145/92, nearly two-thirds said they’d tell him to improve his lifestyle. Shockingly, only one of these practicing physicians was familiar with the recommended thresholds for prescribing drugs, says study author Joseph Ravenell, MD, now at New York University.
In a recent study released by Statistics Canada, 1 in 5 Canadians were shown to have high blood pressure, and 80 per cent of them were being treated with medication.
The right move: If your blood pressure is 140/90 or higher, you should almost certainly be on a prescription hypertension drug—and if one medication doesn’t bring your readings into the normal range, you should be on more than one. Only people diagnosed with prehypertension (120 to 139 over 80 to 89) can get by with lifestyle changes alone. Those include exercising, losing weight if necessary, and eating a healthy, low-fat, low-salt diet.
The immunization mistake your doctor may be making: Not keeping your kids (or you) up-to-date.
The schedule for children’s vaccines is set by the Public Health Agency of Canada, which reviews reams of research on what protects your child best. One key recommendation: Infants and toddlers should get multiple shots to ensure they’re adequately defended against common diseases such as measles and pneumonia. Yet one study found that an alarming 20 per cent of all kids under two miss one or more of the vaccinations. Researchers aren’t sure of all the reasons, but they think part of the explanation is that overwhelmed doctors aren’t properly counselling parents about the importance of multiple shots. Another problem: In 8 per cent of cases, doctors give shots too early or too close together. “If a child gets a booster when the antibodies from an earlier shot are still circulating, it can be almost as if he didn’t get the second one at all,” says the Centers for Disease Control and Prevention epidemiologist Elizabeth T. Luman, PhD.
Physicians are even worse at making sure adults are on track. Only about half of adults are up-to-date on the tetanus booster we’re supposed to get once every decade, for instance. Far fewer get the shingles vaccine—only 6 per cent of adults 60 and up (the recommended age group). Yet shingles can affect anyone who has ever had chicken pox and can be agonizing.
The right move: Kids under two should get multiple shots at nearly all their scheduled well-child visits. One way to reduce aches: Have the doctor give the more-painful pneumonia shot last. (A recent study found this strategy lessens overall soreness.) During your own doctor visits, ask him to check your immunization history against the guidelines. All adults need a tetanus vaccine (which also protects against diphtheria and, in the newest version, whooping cough) once a decade. Other shots you may need—including flu, hepatitis, shingles, HPV, and pneumonia—depend on your age, gender, health history, and occupation.
The asthma mistake your doctor may be making: Treating wheezes instead of preventing them.
Asthma is the most common chronic disease in childhood, affecting 9 per cent of kids. But experts now know that the problem can be effectively controlled. Numerous studies have shown that daily use of inhaled corticosteroids like Advair and Flovent reduces airway inflammation and cuts the frequency and severity of asthma attacks, says Kaiser Permanente asthma expert Michael Schatz, MD, a member of the panel that developed asthma guidelines for the National Institutes of Health. This crucial “control” medicine helps kids sleep better, miss less school, and make fewer scary trips to the ER. Yet a recent study by the Rand Corporation reveals that more than half of asthmatic kids don’t use it. Some parents don’t want or can’t afford the drug—but others aren’t advised that their child needs to keep up with the regimen even after symptoms subside. In many cases, “pediatricians don’t prescribe it because they aren’t aware of its value,” Dr. Schatz admits.
The right move: If your child is over five and has asthma symptoms that strike more than three times a week or keep him or her up at night more than twice a month, your doctor should prescribe an inhaled corticosteroid. For more severe cases, other daily meds may be needed too. (Don’t let the word steroid scare you; the inhaled version isn’t habit-forming, and side effects are generally mild.)
4. Low Back Pain
The low back pain mistake your doctor may be making: Taking pictures of what’s inside your back—and trying to fix what he finds.
MRI rates have skyrocketed—in 2004, doctors performed three times as many MRIs of the spine as they did in 1994. But that isn’t because these pictures are proved to help. In fact, a large body of research, detailed in guidelines by the American Pain Society and the American College of Physicians, cautions against routinely using imaging to figure out the cause of back troubles.
“When you look inside, you see arthritis, degenerative disks, and such. But it turns out many people from midlife on have these things,” says Roger Chou, MD, a coauthor of the guidelines. “And research shows that when you fix them, the pain usually doesn’t go away.”
MRIs aren’t the only problem. Use of epidural steroid shots has quadrupled in the past ten years, though evidence shows they’re only minimally effective. Spinal fusion surgery numbers have grown about threefold, yet research shows that approach, too, frequently does little good.
When a patient hobbles into the office, it’s understandable that the doctor wants to do something, Dr. Chou says. But an unproven intervention can do considerable harm. “It’s worth remembering that back pain has a history of treatments ultimately found to be detrimental, like surgically removing patients’ tailbones,” Dr. Chou says.
The right move: “Back pain can drive you crazy, but it typically improves with steps like taking acetaminophen, using a heating pad, and, if the problem is chronic, starting an exercise program to strengthen back muscles,” Dr. Deyo says. In general, an MRI isn’t necessary unless you have symptoms like severe weakness in your foot or leg, a high fever, problems urinating, or a history of cancer, Dr. Chou advises. Be especially cautious about more aggressive fixes like surgery.
5. Heart Attack
The heart attack mistake your doctor may be making: Not giving emergency treatment fast enough, skipping important aftercare, or missing other critical steps.
For the thousands of Canadians who will have a heart attack this year, immediate treatment with aspirin, clot-busting drugs, angioplasty, or other proven steps could mean the difference between life and death. No wonder these kinds of moves are spelled out in treatment guidelines from the American College of Cardiology and the American Heart Association. Yet fewer than 50 per cent of patients get clot-busting therapy within 30 minutes; about 25 per cent leave the hospital without a referral to cardiac rehabilitation, which is known to be valuable. Other steps can be neglected, as well, if only because a doctor may be distracted by a page or another interruption. In the hectic atmosphere of a hospital, “when you rely only on a doctor’s memory, critical therapies and timetables are easily overlooked,” says Gregg C. Fonarow, MD, associate chief of cardiology at the University of California Los Angeles Medical Center.
So in 2000, the American Heart Association started a program called Get with the Guidelines (GWTG), for hospitals to use as a reminder system. “We view it like an airline pilot checklist. Even if the doctor gets distracted, things are less likely to fall through the cracks,” explains Eric Peterson, MD, director of cardiovascular research at Duke Clinical Research Institute. (The University of Ottawa Heart Institute have worked on a Canadian adaptation of the GWTG called the Champlain Get With The Guidelines Initiative.)
The diabetes mistake your doctor may be making: Failing to test you for diabetes.
About 2 million Canadians have diabetes, yet a third of sufferers don’t know it. That’s a big problem because patients who control their blood sugar can prevent serious complications like leg amputations and heart and kidney disease. Experts say that doctors should keep an eye out for people with high odds of the disease—namely those who are overweight and have other diabetes risk factors. “Yet if a person with these criteria goes in for a specific problem, like a sprained knee, rather than an annual physical, the doctor may not look at the bigger picture and say, ‘You should have a diabetes test,’” says endocrinologist Richard Bergenstal, MD, president-elect of medicine and science at the American Diabetes Association.
The right move: If you have a body mass index (BMI) of or over 25 (the threshold for being considered overweight), plus a second diabetes risk factor such as high blood pressure or high cholesterol, you should be screened for the disease. If the test results show that you’re free of diabetes and prediabetes, you should be tested again within three years.