Fifteen years ago, my 98-year-old Gran crushed her vertebrae turning over in bed. It was agony and she screamed. Our lovely GP told us what had happened, to give her whatever painkillers she could manage and reassured us it would resolve itself. We waited, three weeks later the pain disappeared, and I wrote a letter celebrating ‘the vanishing skill of watchful waiting’ (1). We had avoided medical care, miserable trolleys and saved the National Health Service time and money.

Recently, I found myself in a similar situation when my mum broke her back after a fall. Unfortunately, she was outside, so an ambulance was called and she was taken to A and E. Once in the system, scan after scan followed together with endless consultations with various medical experts and a private ambulance to take her in when she was in too much pain to move. The verdict was a crushed vertebrae and the treatment — painkillers. I went along with the process as it seemed uncaring to say ‘it will be fine’ and ‘just give it time’ and going against the system is hard when you are a daughter, not a doctor. But watching my mum spring off her chair in the MRI waiting room and practically run into the scanner to check that her back had healed, all seemed one medical budget too far. ‘Just look at her,’ I wanted to say. ‘She’s fine!’

There are many reasons why health care in England is on its knees, including an ageing population, patient demand for services, shortages of doctors and lack of funding.

Too many machines

But there is also the issue of unnecessary interventions. In England, imaging scans have increased since 2012 by about 4% and last year, about 47.2 million scans were completed in the NHS. These include x-rays (up 1%), CT scans (up 5.5%), MRI scans (up 6.2%) and SPECT scans (up 5%) (2). A similar pattern can also be seen in the US, with an increase of 3.7% for adults and 5.2% for older adults for CT scans in 2016 compared to 2013 and 1.3% and 2.2% respectively for MRI scans. Although this increase was less than it had been in previous years (3). For many, such increases can be an improvement, bringing quicker diagnosis and a faster transition into treatment if the scan results are positive (4) and they are seen as part of the move towards early detection and better health outcomes.

But scans can also come with possible harm. First, they cost money and require limited resources to be directed from elsewhere. Second, not all scans are 100% effective and many come with false positives, which can lead to unnecessary follow-up treatments. For example, the false positive rate for a mammogram is 10%. Further, they may detect cancers that would not have actually done harm, again leading to unnecessary treatments. Next, there is also the problem of ‘lead times’ when early diagnosis results in treatment but no improvement in life expectancy. The person simply lives for the same time, but no longer, knowing they have cancer. Then on top of all this, there is the anxiety of having a scan, waiting for the result and making sense of the outcome; the time to get to the hospital and the cost of time off work or the transportation (5). Scans are not a benign process and are not always worth the outcome. But once available, it seems hard for doctors not to offer them and for patients to refuse them.

Do we always need to know what’s inside the body?

My Gran was very old and didn’t have many days left. So it was good she didn’t waste those days having tests. My mum, hopefully, has good days ahead of her, but even so, wasted a good few of these having tests that, to me, seemed unnecessary, although they may have been necessary for others. Do we always need to know what the body looks like inside to know how to treat it? Just because machines can do their thing, does it mean they always should? After my gran, I celebrated watchful waiting with the emphasis on the waiting. But now I’d also like to celebrate the looking and the listening bit as well. Patients can tell doctors if it hurts and when it stops hurting. Surely, sometimes that’s enough?

References

1. Ogden J. In praise of the vanishing skill of watchful waiting. Br J Gen Pract. 2016 Dec;66(653):626. doi: 10.3399/bjgp16X688261

3. Smith-Bindman R, Kwan ML, Marlow EC, Theis MK, Bolch W, Cheng SY, Bowles EJA, Duncan JR, Greenlee RT, Kushi LH, Pole JD, Rahm AK, Stout NK, Weinmann S, Miglioretti DL. Trends in Use of Medical Imaging in US Health Care Systems and in Ontario, Canada, 2000-2016. JAMA. 2019 Sep 3;322(9):843-856. doi: 10.1001/jama.2019.11456. PMID: 31479136; PMCID: PMC6724186.

5. Ogden, J. (2016) Do no harm: balancing the costs and benefits of patient outcomes in health psychology research and practice. Journal of Health Psychology DOI: 10.1177/1359105316648760