tag:theconversation.com,2011:/id/topics/choosing-wisely-16537/articlesChoosing Wisely – The Conversation2021-03-22T18:52:20Ztag:theconversation.com,2011:article/1573242021-03-22T18:52:20Z2021-03-22T18:52:20ZMedicinal cannabis to manage chronic pain? We don’t have evidence it works<figure><img src="https://images.theconversation.com/files/390770/original/file-20210322-23-1nms1vc.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4281%2C2843&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As a pain specialist, I often have patients asking me whether they should try medicinal cannabis. There’s a <a href="https://www.painmanagement.org.au/80-general/322-living-with-pain-views-of-medicinal-cannabis.html">common perception</a> it can be an effective way to manage chronic pain.</p>
<p>But two expert groups have recently recommended against medicinal cannabis for people suffering persistent non-cancer pain. </p>
<p>The International Association for the Study of Pain published a <a href="https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=11145&navItemNumber=643">position statement</a> last week after its <a href="https://journals.lww.com/pain/pages/collectiondetails.aspx?TopicalCollectionId=23">presidential taskforce</a> summarised the evidence on the topic. </p>
<p>And yesterday the <a href="https://www.anzca.edu.au/fpm">Faculty of Pain Medicine</a> of the Australian and New Zealand College of Anaesthetists published guidance for health practitioners in the form of a <a href="https://www.choosingwisely.org.au/recommendations/fpm6">Choosing Wisely recommendation</a>. (<a href="https://www.choosingwisely.org.au">Choosing Wisely</a> is an initiative of <a href="https://www.nps.org.au">NPS Medicinewise</a> which aims to highlight low-value health care.)</p>
<p>Many in the community would see this recommendation as controversial. So let’s take a look at some of the commonly held misconceptions about medicinal cannabis and chronic pain.</p>
<h2>Myth #1: evidence shows cannabis products are effective for chronic pain</h2>
<p>Evidence from randomised controlled trials is critically lacking when it comes to medicinal cannabis products for chronic pain. </p>
<p>While some studies have looked at tetrahydrocannabinol (THC, the main psychoactive component of cannabis) or a <a href="https://www.sciencedirect.com/science/article/pii/S0885392409007878">combination of THC and cannabidiol (CBD)</a>, there isn’t a single published randomised controlled trial of a CBD-only product for chronic pain of any type. Australian medicinal cannabis products are <a href="https://freshleafanalytics.com.au/wp-content/uploads/2020/03/Freshleaf-Q1-2020-Report.pdf">often CBD-only</a>.</p>
<p>This means we can’t even judge whether the claims that medicinal cannabis can alleviate pain might be true. The results of THC-containing products in clinical trials don’t give a reliable picture one way or the other because they involve too few participants, have major technical flaws in design, or have been judged to have an unacceptably high risk of producing biased results.</p>
<p>The International Association for the Study of Pain taskforce looked at all the available research published in peer-reviewed journals on the use of medicinal cannabis for pain management, from preclinical studies to human trials. </p>
<p>They <a href="https://journals.lww.com/pain/Abstract/9000/IASP_Presidential_Task_Force_on_Cannabis_and.98091.aspx">concluded</a> overall the studies’ “quality, rigour, and transparency of reporting” of benefits and harms needs to be improved across the board. We would require higher quality data, for example through randomised controlled trials, to determine the safety and efficacy of using medicinal cannabis for pain.</p>
<p>In the polite and understated world of academic medicine, this is about as big a smackdown as it gets. The authors are essentially saying most of the studies are too poorly done, using unsuitable methods, to give any answer to the most basic question of whether medicinal cannabis helps with pain.</p>
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Read more:
<a href="https://theconversation.com/medicinal-cannabis-users-in-victoria-could-soon-be-allowed-to-drive-with-thc-in-their-system-is-it-safe-148345">Medicinal cannabis users in Victoria could soon be allowed to drive with THC in their system. Is it safe?</a>
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<h2>Myth #2: cannabis products should be provided as a ‘last resort’</h2>
<p>A doctor has the right to prescribe any drug they think may be effective for an individual patient based on nothing more than their clinical judgement. We do this relatively frequently, especially for chronic pain. </p>
<p>This is ethical if we have a scientific reason to believe the drug may be helpful. But for patients with chronic pain, we have <a href="https://journals.lww.com/pain/Abstract/2020/02000/Cannabinoid_effects_on_responses_to_quantitative.2.aspx">little reason to believe</a> medicinal cannabis offers any sustained benefit. </p>
<p>A further challenge to the ethical provision of cannabis products as a “last resort” is the fact they’re among the most expensive pharmaceutical products available to chronic pain patients, many of whom have very modest incomes. The only party likely to benefit is the manufacturer. </p>
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<img alt="A senior man talks with a doctor." src="https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390800/original/file-20210322-21-149opw7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Many people who experience chronic pain believe medicinal cannabis could help.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<h2>Myth #3: medical cannabis may help with the opioid crisis</h2>
<p>There’s a consensus that much of the current use of opioid analgesics to manage chronic non-cancer pain in Australia <a href="https://www.anzca.edu.au/getattachment/7d7d2619-6736-4d8e-876e-6f9b2b45c435/PS01(PM)-Statement-regarding-the-use-of-opioid-analgesics-in-patients-with-chronic-non-cancer-pain">may be of limited value</a>. </p>
<p>Proponents of medicinal cannabis have suggested it may <a href="https://theconversation.com/now-that-cannabis-is-legal-lets-use-it-to-tackle-the-opioid-crisis-105114">hold promise</a> as a potential solution to this problem. While this idea has some appeal, the <a href="https://www.businessinsider.com.au/australian-researchers-cannabis-chronic-pain-2018-7">balance of the evidence</a> points the other way. </p>
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Read more:
<a href="https://theconversation.com/1-in-10-women-with-endometriosis-report-using-cannabis-to-ease-their-pain-126516">1 in 10 women with endometriosis report using cannabis to ease their pain</a>
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<p>Data collected from Australia and New Zealand shows participation in best-practice multidisciplinary pain care, as provided by a specialist pain clinic, results in <a href="https://www.painaustralia.org.au/static/uploads/files/electronic-persistent-pain-outcomes-collaboration-14-11-2019-wffowrramcja.jpg">half of pain patients</a> being able to reduce their opioids by at least 50%, with improved quality of life. </p>
<p>People wanting an alternative to opioid treatment for persistent pain will do best if they seek out treatment from a professional team of experts, rather than substituting cannabis for opioids. </p>
<h2>It could be harmful</h2>
<p>The International Association for the Study of Pain taskforce identified <a href="https://journals.lww.com/pain/Abstract/9000/General_risks_of_harm_with_cannabinoids,_cannabis,.98265.aspx">general known risks</a> from using cannabis, such as in recreational settings. But no studies have characterised the way the body handles prescribed or over-the-counter medicinal cannabis products. </p>
<p>The <a href="https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-australia-overview#route">TGA guidance document</a> on medicinal cannabis notes basic research on how the drugs interact with both the body and other medications — known as <a href="https://en.wikipedia.org/wiki/Pharmacokinetics">pharmacokinetic</a> and <a href="https://en.wikipedia.org/wiki/Pharmacodynamics#:%7E:text=Pharmacodynamics%20(PD)%20is%20the%20study,(for%20example%2C%20infection).">pharmacodynamic</a> studies — is not available. Without this information, we can’t answer important questions about the safety of medicinal cannabis.</p>
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<img alt="A collection of white round pills." src="https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390801/original/file-20210322-17-1r2j60e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Medicinal cannabis isn’t the solution to the opioid crisis.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Medicinal cannabis products may have a role in the management of other conditions, such as <a href="https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-treatment-epilepsy-paediatric-and-young-adult-patients-australia">relieving chemotherapy-induced nausea</a>, or <a href="https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-treatment-epilepsy-paediatric-and-young-adult-patients-australia">treating childhood epilepsy</a>. The evidence around those conditions seems to be more convincing than the studies for persistent pain, though I’m not an expert in either field.</p>
<p>Despite the lack of evidence to support the use of medicinal cannabis for chronic pain, the legislation around medicinal cannabis in Australia continues to become more permissive. </p>
<p>It will be <a href="https://www.tga.gov.au/media-release/over-counter-access-low-dose-cannabidiol">legal to sell low-dose CBD products</a> over the counter from June this year, if they meet the very minimal requirements to be listed by the <a href="https://medicalrepublic.com.au/what-does-the-cbd-down-scheduling-mean/36818">Therapeutic Goods Administration</a> (TGA).</p>
<p>Meanwhile, <a href="https://www.abc.net.au/news/2021-03-18/tasmania-cannabis-scheme-explainer/100015178">Tasmania</a> is set to become the last Australian state to allow GPs to prescribe medicinal cannabis from July.</p>
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Read more:
<a href="https://theconversation.com/weed-withdrawal-more-than-half-of-people-using-medical-cannabis-for-pain-experience-withdrawal-symptoms-153841">Weed withdrawal: More than half of people using medical cannabis for pain experience withdrawal symptoms</a>
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<p>The Faculty of Pain Medicine has a track record of advocacy for pain patients. We led the process that resulted in the first ever <a href="https://www.painaustralia.org.au/improving-policy/national-pain-strategy">National Pain Strategy</a> a decade ago, and were a founding partner of <a href="https://www.painaustralia.org.au/">Painaustralia</a> as an ongoing policy voice. </p>
<p>If medicinal cannabis was truly as potentially valuable as often claimed, we would be the loudest voice in favour of wider access. The weight of evidence points us away from this conclusion.</p><img src="https://counter.theconversation.com/content/157324/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Vagg is currently the Dean of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists.
In the last 5 years, payments from pharmaceutical companies for providing educational talks to medical practitioners or other honoraria have constituted less than 0.05% of his gross income. No advisory or marketing advice has been given to the pharmaceutical industry in that time. NPS Medicinewise has paid A/Prof Vagg for consultative services to develop educational materials regarding prescription of pain medications.</span></em></p>We can make the case against using medicinal cannabis to manage chronic pain by debunking three myths.Michael Vagg, Conjoint Clinical Associate Professor, Deakin University School of Medicine and Specialist Pain Medicine Physician, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1246382019-11-11T19:01:05Z2019-11-11T19:01:05ZDodgy treatment: it’s not us, it’s the other lot, say the experts. So who do we believe?<figure><img src="https://images.theconversation.com/files/296329/original/file-20191010-188797-1wp5mk4.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will my surgery work? Well, it depends on who you ask.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/concentrated-surgical-team-operating-patient-operation-1265400856?src=m2MZzzAzKRA2Zx3XNqfTmw-1-3">from www.shutterstock.com</a></span></figcaption></figure><p>Patients might not be getting the best advice about which treatments do or don’t work, according to our study published today. We found professional societies are more likely to call out other health professionals for providing low-value treatments rather than look in their own backyard.</p>
<p>Our study in <a href="https://doi.org/10.1186/s12913-019-4576-1">BMC Health Services Research</a> looked into recommendations under the global <a href="https://www.choosingwisely.org/">Choosing Wisely</a> public health campaign. We found professional societies are reluctant to publish recommendations against treatments and procedures that generate income for their members. </p>
<p>But they are much more comfortable at recommending against treatments that generate income for members of other professional societies.</p>
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Read more:
<a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">Less is the new more: choosing medical tests and treatments wisely</a>
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<h2>How does the Choosing Wisely campaign work?</h2>
<p>Choosing Wisely aims to reduce the use of medical tests, treatments and procedures that provide little-to-no benefit, or in some cases can harm.</p>
<p>It then recommends patients question their doctors about whether these so-called low-value tests, treatments or procedures are necessary.</p>
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<p>To take part in the Choosing Wisely campaign, professional societies publish recommendations relevant to their members.</p>
<p>For example, a surgical society could list a surgical procedure of questionable effectiveness. A physiotherapy society could also list a poorly justified physiotherapy treatment. This ensures recommendations raise awareness of low-value care among the practitioners most likely to provide this care.</p>
<p>However, an <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1314965">ongoing</a> <a href="https://www.bmj.com/content/351/bmj.h6760">concern</a> is whether professional societies focus on low-value care provided by their members or whether they tend to make recommendations for care provided by others, outside their own society.</p>
<p>Many low-value tests, treatments and procedures also generate substantial income for the practitioner who provides them. So societies might be reluctant to recommend against or “call out” these examples of low-value care because of fear of affecting their members’ bottom line.</p>
<h2>What did we do?</h2>
<p>To investigate these concerns, we evaluated all Choosing Wisely recommendations worldwide since the campaign began in 2012.</p>
<p>We reviewed 1,293 recommendations from eight countries, including Australia, to investigate the proportion of recommendations that target income-generating treatments. We also investigated whether recommendations on income-generating treatments were more likely to come from societies involved, or not involved, in providing this care.</p>
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Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
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<p>Treatments or procedures that attract a fee-for-service and are performed outside a routine encounter with a practitioner were considered income-generating for the practitioner performing the treatment. Examples included arthroscopic surgery of the knee and shoulder, cesarean section, removing a breast lump and radiotherapy.</p>
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<a href="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296334/original/file-20191010-188797-7ohdv6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Radiotherapy was one of the treatments counted as income-generating, as part of our study.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-receiving-radiation-therapy-treatments-breast-1097370944?src=J77SkxBy3P-8gXMxgs35Hg-1-0">from www.shutterstock.com</a></span>
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<p>We then examined each recommendation and determined whether the society making the recommendation was targeting a treatment routinely provided by members of their society or members of another society. </p>
<p>There were over 230 professional societies with Choosing Wisely recommendations across medicine, surgery, diagnostic testing and allied health. Examples of professional societies from Australia included the: <a href="https://www.racgp.org.au/">Royal Australian College of General Practitioners</a>; <a href="https://www.surgeons.org/">Royal Australasian College of Surgeons</a>; <a href="https://australian.physio/">Australian Physiotherapy Association</a>; and <a href="https://www.rcpa.edu.au/">Royal College of Pathologists of Australasia</a>.</p>
<h2>Here’s what we found</h2>
<p>Overall, we found only 20% of Choosing Wisely recommendations target income-generating treatments. But more importantly, of these recommendations, most target treatments provided by practitioners that are not members of the society making the recommendation.</p>
<p>For example, the <a href="https://rheumatology.org.au/">Australian Rheumatology Association</a> <a href="http://www.choosingwisely.org.au/recommendations/ara">recommends against</a> arthroscopy for knee osteoarthritis, a surgical intervention that rheumatologists don’t perform (this is generally carried out by orthopaedic surgeons):</p>
<blockquote>
<p>Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.</p>
</blockquote>
<p>Meanwhile, the <a href="https://www.aaos.org/Default.aspx?ssopc=1">American Academy of Orthopaedic Surgeons</a>, whose members perform arthroscopy, doesn’t recommend against the procedure. Instead, it <a href="https://www.choosingwisely.org/societies/american-academy-of-orthopaedic-surgeons/">points the finger</a> at clinicians who routinely provide insoles:</p>
<blockquote>
<p>Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.</p>
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<h2>Why does it matter?</h2>
<p>Choosing Wisely aims to reduce waste in health care. But when societies mainly look for waste in fields other than their own, their recommendations are likely to have less impact. </p>
<p>To illustrate this, eight societies of orthopaedic surgeons have collectively published 48 Choosing Wisely recommendations. But only nine of these recommendations target low-value surgery routinely performed by orthopaedic surgeons. Most of these are from the <a href="https://www.orthopeden.org/">Netherlands Orthopaedic Association</a> (five out of nine recommendations).</p>
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Read more:
<a href="https://theconversation.com/antibiotics-for-colds-x-rays-for-bronchitis-internal-exams-with-pap-tests-the-latest-list-of-tests-to-question-56007">Antibiotics for colds, x-rays for bronchitis, internal exams with pap tests – the latest list of tests to question</a>
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<p>By shying away from publishing recommendations that target ineffective and expensive interventions performed by their own members, professional societies are not acting in line with the spirit of the campaign. </p>
<p>Choosing Wisely could have a large impact on redirecting health-care spending from low-value care to recommended care, thereby improving the lives of millions. But for the campaign to realise its potential, ensuring future recommendations focus on the care provided by members of the society making the recommendation is a good place to start.</p>
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<p><em>Dr John Farey, a surgical registrar affiliated with the Institute for Musculoskeletal Health and the Sydney Local Health District, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/124638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Professional societies of doctors, surgeons or physiotherapists are more likely to recommend against treatments provided by others, our new research shows.Joshua Zadro, Postdoctoral Research Fellow, University of SydneyChristopher Maher, Professor, Sydney School of Public Health, University of SydneyIan Harris, Professor of Orthopaedic Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1025762018-09-06T08:45:59Z2018-09-06T08:45:59ZNeedless procedures: when is a colonoscopy necessary?<figure><img src="https://images.theconversation.com/files/235148/original/file-20180906-190668-3ox800.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Colonoscopies are on the rise in Australia.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>From time to time, we hear or read about medical procedures that can be ineffective and needlessly drive up the nation’s health-care costs. This occasional series explores such <a href="https://theconversation.com/au/topics/needless-treatments-or-procedures-62784">needless treatments or procedures</a> individually and explains why they could cause more harm than good in particular circumstances.</em></p>
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<p>A <a href="https://qualitysafety.bmj.com/content/early/2018/08/06/bmjqs-2018-008338">recent study</a> found up to 20% of all procedures performed in a New South Wales hospital were either unhelpful or harmful. Some of these, which included performing a colonoscopy for constipation, were becoming more prevalent.</p>
<p>A colonoscopy is a test where a small, flexible tube is inserted into the bowel to check for abnormalities such as growths on the bowel, which can lead to bowel cancer.</p>
<p>Around 600,000 colonoscopies were <a href="http://acsqhc.maps.arcgis.com/apps/MapJournal/index.html?appid=4192ad4f3a394c9ca5f7dfed5923698a">performed in Australia</a> in 2013-2014. This figure is expected to rise to more than a million a year by 2020, equivalent to one in every 25 Australians. </p>
<p>A colonoscopy is an invasive procedure and comes with risks, including bowel perforation. So, it’s important to have the test only if you’re likely to benefit from it.</p>
<h2>Why are colonoscopies performed?</h2>
<p>Bowel cancer is the <a href="https://bowel-cancer.canceraustralia.gov.au/statistics">second-most-common</a> cause of cancer-related death in Australia. Current <a href="https://www.ncbi.nlm.nih.gov/pubmed/22356322">evidence suggests</a> colonoscopy significantly reduces the risk of bowel cancers. This is where colonoscopy’s greatest benefit lies. Colonoscopy can also be used to diagnose inflammatory bowel diseases.</p>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-inflammatory-bowel-disease-15173">Explainer: what is inflammatory bowel disease?</a>
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<p>Bowel cancers start out as small growths in the bowel called polyps. These can be seen with a colonoscopy and cut out by doctors during the test. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=628&fit=crop&dpr=1 600w, https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=628&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=628&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=789&fit=crop&dpr=1 754w, https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=789&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/235152/original/file-20180906-190673-1p20y1l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=789&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A colonoscopy can check for polyps, which are small growths on the bowel.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>So, colonoscopy is more worthwhile when done in people at an increased risk of bowel cancer. The most important risk factor is age, as cancer rates increase in people older than 50.</p>
<p>But some younger people can be at risk due to family history. And <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/25251195/?i=5&from=/23011536/related">recent data suggest</a> bowel cancer in young people is rising here and internationally, though we’re not sure why.</p>
<h2>Who should have a colonoscopy?</h2>
<p>A doctor will usually recommend a colonoscopy if patients are at increased risk of bowel cancer due to family history (particularly first-degree relatives who develop bowel cancer before the age of 55), if their “poo test” is positive for blood, or if they have concerning symptoms such as bleeding.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/pre-cancerous-warning-sign-or-cause-for-panic-94916">Pre-cancerous: warning sign or cause for panic?</a>
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<p>An <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2036.2010.04344">Australian study</a> tried to determine which symptoms could best predict bowel cancer. The authors collected data on around 8,000 patients with a range of symptoms – including rectal bleeding and constipation – undergoing colonoscopy. They followed them to see who was diagnosed with a cancer (or a large polyp) during the colonoscopy. </p>
<p>They found that, apart from age, rectal bleeding was the strongest predictor of bowel cancer. Other common symptoms such as abdominal pain or constipation alone were not associated with bowel cancer, suggesting colonoscopy in these cases was unnecessary. These <a href="https://www.ncbi.nlm.nih.gov/pubmed/18676420">findings</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19935790">have been</a> <a href="https://gut.bmj.com/content/65/Suppl_1/A225.2">replicated</a> in <a href="https://www.ncbi.nlm.nih.gov/pubmed/21689337">other studies</a>.</p>
<h2>When not to have a colonoscopy</h2>
<p>Small polyps grow slowly and may take ten years or longer (if at all) to develop into bowel cancer. This is why it is considered inappropriate to <a href="http://www.choosingwisely.org/clinician-lists/american-college-surgeons-colorectal-cancer-screening-tests/">continue screening</a> in people aged over 75.</p>
<p>International speciality groups <a href="https://www.ncbi.nlm.nih.gov/pubmed/18938166">don’t recommend</a> ongoing screening when life expectancy is less than ten years, because many people will not benefit. And they will be exposed to the risks of colonoscopy, including bowel perforation and major bleeding. <a href="https://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer">Australian guidelines</a> also recommend stopping colonoscopy in people aged around 75.</p>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/costly-and-harmful-we-need-to-tame-the-tsunami-of-too-much-medicine-48239">Costly and harmful: we need to tame the tsunami of too much medicine</a>
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<p>In young people, colonoscopy is often performed to look for inflammatory bowel disease, but new non-invasive stool tests can select out people at higher risk. Young people with irritable bowel syndrome may also undergo repeated colonoscopies to try to find an alternative reason for their symptoms, but this strategy is usually unhelpful.</p>
<h2>Why are colonoscopies on the rise?</h2>
<p>Australia’s population is ageing and the number of people older than 55 is increasing.</p>
<p>Consumer demand can also drive unnecessary testing. Evidence shows that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25531451">people frequently overestimate</a> the benefits and underestimate the harms of tests such as colonoscopy. Often there’s a misconception that more tests and more health care leads to better health, when data suggest the opposite is true. </p>
<p>The global <a href="http://www.choosingwisely.org.au/home">Choosing Wisely</a> campaign aims to educate consumers about risks of over-testing. In the future, <a href="http://www.nature.com/articles/nrgastro.2018.1">symptoms-based algorithms</a> and new diagnostic tests might improve a doctor’s ability to identify those at increased risk of bowel cancer for colonoscopy. </p>
<p>In the meantime, prioritising colonoscopy for patients who are at higher risk should be the goal.</p>
<hr>
<p><em>This article previously said a study had found around 30% of procedures in a NSW hospital were unhelpful or harmful. This has been corrected to up to 20% of procedures.</em></p><img src="https://counter.theconversation.com/content/102576/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Mahady does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A colonoscopy is usually done to diagnose bowel cancer. It is an invasive procedure with risks such as bowel perforation. It’s important to only have the test if you’re likely to benefit.Suzanne Mahady, Gastroenterologist & Clinical Epidemiologist, Senior Lecturer, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/918292018-02-19T18:48:00Z2018-02-19T18:48:00ZNeedless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work<figure><img src="https://images.theconversation.com/files/206904/original/file-20180219-75987-p1xpj7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Back pain affects one-quarter of Australians.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>From time to time, we hear or read about medical procedures that can be ineffective and needlessly drive up the nation’s health-care costs. This occasional series explores such <a href="https://theconversation.com/au/topics/needless-treatments-or-procedures-62784">needless treatments or procedures</a> individually and explains why they could cause more harm than good in particular circumstances.</em></p>
<hr>
<p>Back pain affects <a href="https://www.ncbi.nlm.nih.gov/pubmed/15148462">one in four</a> Australians. It’s so common, nearly all of us (<a href="https://www.ncbi.nlm.nih.gov/pubmed/27745712">about 85%</a>) will have at least one episode at some stage of our lives. It’s one of the most common reasons <a href="https://www.ncbi.nlm.nih.gov/pubmed/23529466">to visit a GP</a> and the main health condition forcing older Australians to <a href="https://www.ncbi.nlm.nih.gov/pubmed/18928439">retire prematurely</a> from the workforce. </p>
<p>Treatment costs for back pain in Australia total almost <a href="https://trove.nla.gov.au/work/185011445?q&versionId=201465733">A$5 billion</a> every year. A great proportion of this is spent on spinal surgical procedures. Recently, Choosing Wisely, the campaign to educate medical professionals and the public about tests, treatments and procedures that have little benefit, or lead to harm, <a href="http://www.choosingwisely.org.au/recommendations/fpm">added spinal fusion</a> for lower back pain to its list.</p>
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<strong>
Read more:
<a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">Australians are undergoing unnecessary surgery – here's what we can do about it</a>
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<p>This is because, despite rates of the procedure being on the rise, current evidence doesn’t support spinal fusion for back pain. Randomised trials (regarded as studies providing the highest-quality evidence) suggest <a href="https://www.ncbi.nlm.nih.gov/pubmed/24346052">spinal fusion has little advantage</a> over a well-structured rehabilitation program, or psychological interventions, for back pain.</p>
<h2>What is spinal fusion?</h2>
<p>Spinal surgery is most commonly performed to remove pressure on nerves that causes pain and other nerve symptoms in the legs. This surgery is called decompression. The next most common procedure is spinal fusion, where two or more vertebrae are joined together (using such methods as transplanted bone from the patient, a donor or artificial bone substitutes) to stop them moving on each other and make one solid bone.</p>
<p>Spinal fusion may be performed for fractures, dislocations and tumours, and is commonly performed in conjunction with decompression. For back pain, it’s performed when the origin of the pain is thought to be related to abnormal or painful movement between the vertebrae (from degenerative joints and discs, for example).</p>
<p>Rates of spinal fusions <a href="https://www.ncbi.nlm.nih.gov/pubmed/17077740">have been rising</a> and continue to increase, outstripping other surgical procedures for back pain. In the United States, rates of spinal fusion more than doubled from 2000 to 2009. In Australia, rates <a href="https://www.ncbi.nlm.nih.gov/pubmed/25281920">increased </a> by 167% in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20078526">private sector</a> between 1997 and 2006, despite almost no increase in the public sector.</p>
<p>Spinal fusion rates <a href="https://www.safetyandquality.gov.au/atlas/atlas-2015/">differ significantly</a> between regions of Australia, with the highest being in Tasmania and the lowest in South Australia: a seven-fold variation. Significant variations are also seen between countries. For instance, spinal fusion rates in the United States are <a href="https://www.ncbi.nlm.nih.gov/pubmed/8747260">eight times</a> those in the United Kingdom.</p>
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<a href="https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/206911/original/file-20180219-75974-agn2n1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Rates of spinal surgery are on the rise, despite little evidence of effectiveness.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>The greatest increase in the use of spinal fusion has been in <a href="https://www.ncbi.nlm.nih.gov/pubmed/28441309">older Australians</a>, often in conjunction with decompression surgery for spinal stenosis – a condition that causes narrowing of the spinal canal (the cavity that runs through the spinal cord). </p>
<p>Differences in clinical training, professional opinion, and local practices are likely to play a role in such variations.</p>
<h2>Evidence for spinal surgery</h2>
<p>There is little high-quality evidence to support the use of spinal fusion for most back-related conditions, including <a href="https://www.ncbi.nlm.nih.gov/pubmed/27801521">spinal stenosis</a>. And there is <a href="https://www.ncbi.nlm.nih.gov/pubmed/12211665">disagreement between surgeons</a> on when spinal fusion surgery should be performed, not only for back pain but also for more acute conditions such as tumours and spine fractures. </p>
<p>There have also been no studies comparing spinal fusion to a placebo procedure. Most research to date compares one fusion technique to <a href="https://www.ncbi.nlm.nih.gov/pubmed/29367001">another technique</a> or to a form of <a href="https://www.ncbi.nlm.nih.gov/pubmed/24346052">non-surgical treatment</a>, so we still don’t know whether spine fusion is effective against placebo.</p>
<p>We also know that spine fusion surgery is expensive and associated with <a href="https://www.ncbi.nlm.nih.gov/pubmed/20371784">more complications</a> than decompression surgery. And the surgery often fails. Around <a href="https://www.ncbi.nlm.nih.gov/pubmed/17268274">one in five</a> patients who undergo spine fusion will have revision surgery within ten years. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/20736894">Research also shows</a> most patients having spine fusion surgery under workers’ compensation won’t return to the usual job, will still be having physiotherapy and be on opioid medication two years after surgery.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/thinking-of-taking-opioids-for-low-back-pain-heres-what-you-need-to-know-88012">Thinking of taking opioids for low back pain? Here's what you need to know</a>
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</p>
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<h2>So why are rates going up?</h2>
<p>There are <a href="https://www.ncbi.nlm.nih.gov/pubmed/14960750">several factors</a>, including an ageing population, that may contribute to the rapid increase in spinal fusion despite the lack of evidence supporting its use. Financial incentives might also explain the differences in rates between private and public sectors in Australia and between the United Kingdom and the United States.</p>
<p>We don’t have high-quality evidence on the benefits and harms of spinal fusion. This means there is uncertainty, which allows practitioners to continue doing the procedures they were trained to do unchallenged. This then leads to overtreatment, particularly where reimbursement rates are high, such as in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24210578">workers’ compensation</a> setting. </p>
<p>Uncertainty about the appropriateness of spine fusion results in practice variation, wastes scarce health care resources and leads to worse patient outcomes. </p>
<p>We need better research in this area. This means research efforts should shift from studies looking at different ways of performing the surgery and focus on investigating whether or not it works better than non-operative treatments or a placebo, and, if so, whether the benefits outweigh the harms.</p>
<p>In the absence of such evidence, patients can consider other evidence-based and less costly treatments, such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/27745712">exercise, cognitive behavioural therapy and physiotherapy</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ouch-the-drugs-dont-work-for-back-pain-but-heres-what-does-72283">Ouch! The drugs don't work for back pain, but here's what does</a>
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<img src="https://counter.theconversation.com/content/91829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gustavo Machado receives funding from the National Health and Medical Research Council for his fellowship.</span></em></p><p class="fine-print"><em><span>Christine Lin receives funding from the National Health and Research Council for her fellowship and a current project investigating the effects of opioid analgesics in spinal pain.</span></em></p><p class="fine-print"><em><span>Ian Harris receives a salary from UNSW and South Western Sydney Local Health District and income from surgical practice. His research unit has received competitive grant funding from the NHMRC, the Medical Research Futures Fund, State Insurance Regulatory Authority (NSW), HCF Research Foundation, Australian Orthopaedic Association, the Lincoln Foundation, and the AO Foundation. He receives royalties from a book: Surgery, the Ultimate Placebo.</span></em></p>Rates of spinal fusion surgery for back pain are on the rise. This is despite little evidence that it’s an effective procedure and studies showing many will have revision surgery within ten years.Gustavo Machado, NHMRC Early Career Fellow, University of SydneyChristine Lin, Principal Research Fellow and Associate Professor, University of SydneyIan Harris, Professor of Orthopaedic Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/669062016-10-14T05:48:40Z2016-10-14T05:48:40ZGenetic testing isn’t a crystal ball for your health<figure><img src="https://images.theconversation.com/files/141554/original/image-20161013-16233-2a0th1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Providing a sample for a genetic test might not actually give you the health answers you're looking for. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/canadianbloodservices/4911111788/in/photolist-8tYLfj-8tYJrb-9mHqxS-cFfpQG-armU2W-9J1e8L-7XuJsc-6Vzv4K-8KDLxZ-82XgoT-831qhj-82Xh2B-cfvYXs-8KDTTi-8KDJBM-831qrG-5nWpRY-831qxQ-8x7gBf-4GBNB6-fmPUiZ-ehLDn2-27khX2-8UrG7R-5xY1GH-8UuvZf">Canadian Blood Services/flickr </a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Choosing Wisely Australia has released its <a href="http://www.choosingwisely.org.au/latest">latest recommendations</a> on the use of genetic testing, suggesting people avoid genetic tests for Alzheimer’s (<a href="http://www.nature.com/gim/journal/v13/n6/full/gim9201195a.html">APOE</a>), coeliac disease and folate conversion (<a href="https://www.ncbi.nlm.nih.gov/pubmed/23288205">MTHFR</a>).</p>
<p>Testing these genes is not recommended as results do not lead to improved health outcomes, and may create anxiety or false hope among patients. </p>
<p>Led by Australia’s health colleges, societies and associations and facilitated by <a href="http://www.nps.org.au/">NPS MedicineWise</a>, <a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">the Choosing Wisely initiative</a> drives conversations for the health care community and consumers about eliminating the use of unnecessary and sometimes harmful tests, treatments, and procedures. </p>
<h2>Genetic testing as a health care tool</h2>
<p>Genetic testing is currently available for <a href="https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=43">more than 2,000 rare and common conditions</a>. It is an important tool for the diagnosis of rare and inherited conditions such as <a href="http://www.genetics.edu.au/Publications-and-Resources/Genetics-Fact-Sheets">cystic fibrosis</a>. It can also guide health care and decisions for families with a strong history of <a href="http://www.racgp.org.au/afp/2014/januaryfebruary/family-history-of-breast-cancer/">cancer</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed?term=Watts%20G,%20Sullivan%20D,%20Poplawski%20N,%20et%20al.%20Familial%20hypercholesterolaemia:%20a%20model%20of%20care%20for%20Australasia.%20Atherosclerosis%202011;12(Suppl%202):221%E2%80%9331.">high cholesterol</a>. </p>
<p>However, its use it not always justified.</p>
<p>Genetic testing involves analysis of a person’s DNA: it looks for variants in genes that have an impact on our health. However many variants do not have a strong association with disease. Indeed, for many we don’t know what affect they have at all. </p>
<p>When the evidence for an association between a genetic variant and a health outcome is weak, genetic testing does not add any value for the health professional in making decisions about treatment and patient management. This reflects the fact that <a href="https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/g9_direct_to_consumer_genetic_testing_nhmrc_statement_141208.pdf">gene variants are common in our DNA</a> and often not responsible for disease symptoms.</p>
<p>MTHFR and APOE are examples of genes with known and common variants that are poorly correlated with predicting future health risks. </p>
<h2>Genetic testing to assess folate conversion</h2>
<p><a href="https://theconversation.com/adding-folic-acid-to-staple-foods-can-prevent-birth-defects-but-most-countries-dont-do-it-55533">Folate and folic acid </a> are forms of the vitamin B9. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/23288205">MTHFR (5,10-methylenetetrahydrofolate reductase) gene</a> is involved in converting the vitamin into a form the body can use. </p>
<p>There are <a href="http://www.racgp.org.au/afp/2016/april/mthfr-genetic-testing-controversy-and-clinical-implications/">two common variants in the MTHFR gene</a>, and 60–70% of the general population will have at least one of these variants. </p>
<p>People with MTHFR variants still usually convert sufficient folate for the body to function as normal. With a good diet, the <a href="http://www.racgp.org.au/afp/2016/april/mthfr-genetic-testing-controversy-and-clinical-implications/">effects of a MTHFR variant can be easily overridden</a>.</p>
<p>Low levels of folate are known to <a href="https://www.ranzcog.edu.au/college-statements-guidelines.html">increase the risk of neural tube defects</a>, where part of a baby’s brain or spinal cord does not form correctly during pregnancy. <a href="https://www.ranzcog.edu.au/college-statements-guidelines.html#obstetrics">Australian women are advised</a> to take folic acid for a minimum of one month before conception and for the first three months of pregnancy, irrespective of their MTHFR gene variant status. </p>
<p>Although variants in the MTHFR gene have been suggested to play a role in some blood clotting disorders and heart disease, there is <a href="https://www.ncbi.nlm.nih.gov/pubmed/20937919">insufficient evidence</a> to show that MTHFR variants have any significant impact on these conditions. </p>
<p>Even though folate deficiency in Australia is rare, and people with variants of MTHFR can still convert sufficient folate for good health, there has been a <a href="http://www.racgp.org.au/afp/2016/april/mthfr-genetic-testing-controversy-and-clinical-implications/">rapid increase</a> in consumer-driven MTHFR gene testing as part of “healthy lifestyle” testing. </p>
<p>GPs and genetic clinics also <a href="http://www.racgp.org.au/afp/2016/april/mthfr-genetic-testing-controversy-and-clinical-implications/">report</a> high levels of anxiety among clients seeking clinical advice about their MTHFR test results.</p>
<p>MTHFR genetic testing is not recommended. </p>
<h2>Genetic testing for Alzheimer’s disease</h2>
<p>There are a number of <a>well known variants</a> in the APOE (apolipoprotein E) gene. The APOE E4 form of this gene is often suggested to have a connection <a href="http://www.nature.com/gim/journal/v13/n6/full/gim9201195a.html">with the late-onset form of Alzheimer’s disease</a>, affecting people aged 60 years and over. </p>
<p>However this variant has been found in healthy members of the community as well as those who develop Alzheimer’s disease. Until more is known about the role of the APOE gene, <a href="http://www.genetics.edu.au/Publications-and-Resources/Genetics-Fact-Sheets/FS50ALZHEIMERDISEASE.pdf">determining which form of the gene is present can’t predict</a> accurately whether a person is predisposed to develop the condition. </p>
<p>Current genetic tests that claim to predict risk of Alzheimer’s disease based on APOE are therefore limited and unlikely to do anything other than create unnecessary anxiety. </p>
<p>It can also create a false sense of security because late-onset Alzheimer’s disease also develops in people who don’t carry the APOE E4 variant.</p>
<p>But <a href="http://www.nature.com/gim/journal/v13/n6/full/gim9201195a.html">familial factors do influence the risk of dementia</a>. People with dementia occurring in later life – of which Alzheimer’s disease is the most common form – are about three times more likely to have a parent or sibling with dementia. </p>
<p>Late onset Alzheimer’s disease must not be confused with a very rare form of early onset familial Alzheimer’s disease. Symptoms usually start well before 65 years of age and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857183/">genetic testing of particular genes</a> may be considered for this specific condition.</p>
<h2>Genetic testing for coeliac disease</h2>
<p><a href="http://www.mayoclinic.org/diseases-conditions/celiac-disease/home/ovc-20214625">Coeliac disease</a> is a condition in which the immune system is abnormally sensitive to gluten, a protein found in wheat, rye and barley. When coeliac disease is not well managed it can lead to diarrhoea, fatigue, weight loss, bloating and anaemia, and more serious complications. </p>
<p>Although variants in genes that provide instructions for making proteins in the immune system <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/coeliac-disease-and-gluten-sensitivity">can indicate</a> an increased risk of developing coeliac disease, this field of research is still relatively young. </p>
<p>The new Choosing Wisely Australia recommendation reflects The Gastroenterological Society of Australia’s view that a genetic test should not currently be used to diagnose coeliac disease. Professor Anne Duggan from the society says, </p>
<blockquote>
<p>As a coeliac gene can be found in one-third of the population and a positive result does not make coeliac disease a certainty, serological testing is the appropriate first-line screening tests for coeliac disease. </p>
</blockquote>
<p><a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/coeliac-disease-and-gluten-sensitivity">Serological testing</a> measures levels of specific antibodies in blood, and can be followed up with intestinal biopsies for confirmation. </p>
<h2>Consumer driven genetic testing</h2>
<p>Clear health benefits have come from the rapid development of genetic technologies and increased availability of genetic testing. However, genetic tests are complex. Results often require interpretation from an experienced practitioner, as they have multiple possible outcomes and levels of certainty.</p>
<p>When health consumers undertake testing without the involvement of a health professional, there is <a href="https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/g9_direct_to_consumer_genetic_testing_nhmrc_statement_141208.pdf">potential for misinterpretation</a> of results, inappropriate further investigations and treatment, unnecessary anxiety and false reassurance. </p>
<p>Genetic testing results can have implications for family members due to the shared nature of genetic information in families. Misinterpretation and anxiety may be exacerbated as results are relayed to relatives.</p>
<p>With the increase trend towards direct-to-consumer testing – where tests are purchased directly by consumers, often over the internet and usually without the involvement of a health professional – and the translation of testing into mainstream medicine, guidelines from Choosing Wisely Australia are timely. </p>
<p>With the advent of new technologies, we must be circumspect about the validity of testing and over-testing and aim to avoid causing patients and their families unnecessary harm. </p>
<p>Genetic testing is best performed in a clinical setting with the provision of personalised genetic counselling and professional interpretation of tests results.</p><img src="https://counter.theconversation.com/content/66906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Dunlop receives funding from NHMRC. </span></em></p>Testing some genes for Alzheimer’s disease, coeliac disease and folate conversion does not lead to improved health outcomes, and may create anxiety or false hope amongst patients.Kate Dunlop, Director of the Centre for Genetics Education, NSW and Clinical Lecturer, Sydney Medical School-Northern, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/560072016-03-15T19:08:01Z2016-03-15T19:08:01ZAntibiotics for colds, x-rays for bronchitis, internal exams with pap tests – the latest list of tests to question<figure><img src="https://images.theconversation.com/files/115059/original/image-20160315-17766-1oucbfb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Among the 61 recommendations is: 'Don’t order chest x-rays in patients with uncomplicated acute bronchitis'.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>The problem of questionable treatment and tests which may provide little or no benefit, yet may cause harm, is ubiquitous across all areas of health care. </p>
<p>Harm doesn’t just come in the form of side-effects or further testing. The “cons” of any treatment or test also include the costs, which can be financial, emotional, and the costs of the individual’s time. </p>
<p>The <a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">Choosing Wisely campaign</a> encourages patients and clinicians to question unnecessary treatments. First launched in America in 2012 and in Australia last year, the clinician-led initiative collates lists of tests, treatments and procedures that provide little or no value, and which may cause harm. </p>
<p>Today the Australian organisers, NPS MedicineWise, will release an additional 61 recommendations. These include:</p>
<ul>
<li><p>Don’t order chest x-rays in patients with uncomplicated acute bronchitis (<em>Routine chest x-rays don’t improve outcomes and may lead to false positives, further investigations and unnecessary radiation</em>)</p></li>
<li><p>Avoid prescribing antibiotics for upper respiratory tract infections, also known as the common cold (<em>Most uncomplicated upper respiratory infections are viral and antibiotic therapy isn’t suitable</em>)</p></li>
<li><p>Don’t initiate medicines to prevent disease in patients who have a limited life expectancy (<em>There is limited evidence to support the use of many medicines in frail, elderly patients who are more susceptible to the side-effects of medicines</em>) </p></li>
<li><p>Don’t routinely do a pelvic examination with a pap smear (<em>The procedure can cause pain, fear, anxiety and embarrassment and can lead to unnecessary, invasive and potentially harmful diagnostic procedures</em>)</p></li>
<li><p>Don’t request imaging for patients with non-specific low back pain (<em>Trials have consistently shown there is no advantage from routine imaging of non-specific low back pain and there are potential harms</em>).</p></li>
</ul>
<p>The need for informed conversations about potentially unnecessary treatments, tests and procedures is certainly not restricted to only the medical professions.</p>
<p>As well as the medical colleges and societies involved, it is encouraging that in this second release, organisations which represent nurses and allied health professionals such as physiotherapists and hospital pharmacists have participated. Hopefully in future releases, we will see more of Australia’s allied health organisations becoming involved in Choosing Wisely. </p>
<p>As with the <a href="https://theconversation.com/less-is-the-new-more-choosing-medical-tests-and-treatments-wisely-40756">2015 lists</a>, most of the recommendations are about doing less. Only a few are about encouraging a particular action to be done. An example is having an earlier conversation about prognosis, wishes, values and end of life in patients with advanced disease. </p>
<p>This may be because we clinicians are guilty more often of doing too much than too little. </p>
<p>This is counter-intuitive to most of us. Somehow, the thought that a clinician might have not done enough feels more reprehensible than their having done too much. And this is not just what patients might think – it’s probably true of many clinicians as well. </p>
<p>The memories of many junior hospital doctors probably include over-ordering tests (“just in case”, but also to demonstrate their knowledge of rare diagnostic possibilities) to avoid their seniors criticising them during an upcoming ward round. </p>
<p>The realisation that patients can actually be harmed more by receiving unnecessary tests, procedures, and treatments, than by not having received them has been painfully slow. </p>
<p>The Choosing Wisely campaign helps to signal a very important departure from normal business for clinicians and their organisations – thinking about <em>not</em> doing things. </p>
<p>While one of the drivers behind the Choosing Wisely campaign is reducing the tests and treatments people receive that provide little or no benefit, another is minimising the harm that can result from them. </p>
<p>For many of the recommendations, the harm is one that affects the individual. Quite a few of the recommendations are about not doing medical imaging and screening (such as not requesting imaging for non-specific low back pain). These typify individual harm – for example, unnecessary radiation exposure increases the risk of cancer. </p>
<p>Then there is a cluster of recommendations about the wise use of antibiotics. Antibiotic use has the interesting peculiarity of potentially causing harm to both individual patients and the community. We know that antibiotics – which can be life-saving for some serious infections such as meningitis and pneumonia – have little benefits to the common coughs and colds that make up a huge proportion of general practitioner visits. On balance, these benefits are of the same order as the common harms they cause (such as vaginal or oral thrush, diarrhoea, rashes, and so on). </p>
<p>But another important harm is the risk of inducing resistance. Antibiotic resistance – when bacteria adapt and antibiotics fail – is a deepening crisis that is <a href="https://theconversation.com/antibiotic-resistance-sorry-not-my-problem-44011">already killing thousands directly</a> and may soon disrupt many routine clinical procedures. </p>
<p>Antibiotic resistance is a direct result of antibiotic use. The more antibiotics are used when they are not needed, the less likely they are to be effective when needed for a bacterial infection. </p>
<p>So while the unnecessary use of antibiotics has potential harms to the individual, it can also contribute to the restricted use of antibiotics by others in the community who do need it. </p>
<p>For all of the recommendations, there is the harm to society that occurs from the wasted resources and cost of providing unnecessary tests and treatments, often at the expense of more effective uses of precious health care dollars. </p>
<p>But the premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients. </p>
<p>No test or treatment should be provided to a patient <a href="https://www.mja.com.au/journal/2014/201/1/shared-decision-making-what-do-clinicians-need-know-and-why-should-they-bother">without a conversation</a> between the patient and clinician, during which the options (including the option of doing nothing), their benefits and harms, and the patient’s preferences and values <a href="http://www.choosingwisely.org.au/5-questions-to-ask-your-doctor">are discussed</a>.</p><img src="https://counter.theconversation.com/content/56007/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tammy Hoffmann has received funding from the NHMRC and ACSQHC for research about shared decision making.</span></em></p><p class="fine-print"><em><span>Chris Del Mar receives funding from the NHMRC and ACSQHC for related research </span></em></p>Harm doesn’t just come in the form of side-effects or further testing. The “cons” of any treatment also include the costs, which can be financial, emotional, and the costs of the individual’s time.Tammy Hoffmann, Professor of Clinical Epidemiology, Bond UniversityChris Del Mar, Professor of Public Health, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/460892015-08-16T20:27:00Z2015-08-16T20:27:00ZAustralians are undergoing unnecessary surgery – here’s what we can do about it<p>For decades, clinicians and researchers have been concerned about patients getting treatments, including operations, that don’t work. As well as failing to treat the original health problem, ineffective care exposes patients to complications and side-effects and waste precious health-care resources.</p>
<p>Yet while many clinicians believe there is a problem, the policy response has been limited. It is often hard to isolate treatment choices that are inappropriate. A choice that is wrong in one case may be right in another. </p>
<p>To avoid ineffective treatments, we need a new way to identify and reduce questionable care. A new <a href="http://grattan.edu.au/home/health/">Grattan Institute report</a> shows how to do it.</p>
<h2>Warning signs</h2>
<p>The report follows up two clues that treatment choices are sometimes wrong. </p>
<p>The first is <a href="http://www.dartmouthatlas.org/downloads/atlases/Surgical_Atlas_2014.pdf">geographic variation</a>. In 2010-11, there were 1.3 tonsillectomies for every 1,000 people in Western Sydney. Along the Great South Coast in Victoria (the area around Warrnambool), the rate is 7.4 (these rates are adjusted for age and sex). It seems unlikely that <a href="http://www.oecd-ilibrary.org/social-issues-migration-health/geographic-variations-in-health-care_9789264216594-en">variation this large</a> is just a matter or people in some areas being sicker or more willing to go under the knife.</p>
<p>But while geographic variation is troubling, it is inconclusive. Some of it <a href="http://www.brookings.edu/%7E/media/projects/bpea/fall%202014/fall2014bpea_sheiner.pdf">can be explained</a> by factors such as how sick people are, but not all of it. </p>
<p>It is also hard to tell if over-servicing or under-servicing is the problem. Are people in areas with high rates of surgery getting too much, or are people elsewhere getting too little? </p>
<p>Finally, variation is typically measured among regions. That can make it hard to tell which providers are behind it. For all these reasons, years of <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(13)00307-2/fulltext">debate and commentary</a> about clinical variation has resulted in little policy action.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Public and private hospitals should be given time to examine their own practices.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-144372445/stock-photo-ashkelon-isr-july-doctor-on-duty-in-barzilai-medical-center-emergency-department-on-july.html?src=54uMwyR6LaJMwQIy7J7p2Q-1-56">ChameleonsEye/Shutterstock</a></span>
</figcaption>
</figure>
<p>The second clue that alerts us questionable care is the use of treatments we know are ineffective for certain types of patients. Clinical research <a href="https://www.nice.org.uk/guidance/cg137/resources/search-the-nice-do-not-do-recommendations-database.">has uncovered</a> hundreds of treatments that don’t work for certain types of patients. These treatments have been targeted for reduction or removal. Australian medical colleges have <a href="http://www.choosingwisely.org.au/">recently listed treatments</a> that should be questioned in discussions between doctors and their patients.</p>
<p>Like clinical variation, ineffective care has been widely discussed but still persists. It is very hard to find treatments that are always wrong and efforts to shift treatment choices are sometimes met with indifference, <a href="https://www.health.qld.gov.au/healthpact/docs/papers/workshop/disinvestment-report.pdf">resistance</a> or <a href="http://europepmc.org/articles/pmc4010873">gaming</a>. </p>
<p>For instance, powerful <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa013259">evidence</a> shows that a certain type of arthroscopy – inserting a tube to remove tissue – <a href="http://www.prairietrailphysio.ca/_downloads/Kirkley-et-al-2008.pdf">won’t help people</a> with knee osteoarthritis. But it still happens at least 800 times a year in Australian hospitals.</p>
<h2>What should be done?</h2>
<p>The first step to address the problem is to provide better information. Clinicians cannot keep track of all the evidence published each year. Much of the <a href="https://www.nhmrc.gov.au/guidelines-publications/nh165">guidance</a> that summarise the evidence is flawed. We recommend that a body such as the <a href="http://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Health Care</a> develop and publish clear guidance about which procedures should be avoided.</p>
<p>The second step is to monitor whether this guidance translates into practice. To show how this can be done, we measured how often hospitals provide five examples of do-not-do treatments. They are treatments that <a href="http://www.nice.org.uk/">evidence</a>, and usually <a href="http://www.msac.gov.au/">government bodies</a>, say should not be given to certain types of patient:</p>
<ul>
<li><p>Vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement </p></li>
<li><p>Arthroscopic debridement for osteoarthritis of the knee: inserting a tube to remove tissue </p></li>
<li><p>Laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres </p></li>
<li><p>Removing healthy ovaries during a hysterectomy </p></li>
<li><p>Hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.</p></li>
</ul>
<p>Our analysis combines the two big clues about questionable care: variation and ineffective care. It looks at treatments that we know are ineffective and identifies hospitals that are furthest from normal clinical practices. </p>
<p>This exposes outliers with troubling patterns of care. While many hospitals never provide the do-not-do treatments, some outlier hospitals provide them at more than ten times the average rate.</p>
<p><strong>Some public hospitals give do-not-do treatments far more often than average</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=649&fit=crop&dpr=1 600w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=649&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=649&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=816&fit=crop&dpr=1 754w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=816&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=816&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</figure>
<p>The Australian Commission on Safety and Quality in Health Care should report these results to hospitals, states and health insurers. Clinicians should know when they are out of step with the evidence and their peers.</p>
<p>But that won’t always be enough. When high rates of do-not-do procedures persist, states and insurers must take action. In theory, these treatments should never happen, but in practice they might sometimes be needed. For this reason, we recommend a cautious approach that uses data to drive expert clinical evaluation.</p>
<p>Public and private hospitals should be given time to examine their own practices. If after a year they still perform a do-not-do procedure at an above-average rate, the state government should initiate a clinical review of the hospital’s practices. Then doctors who perform the procedures can explain why to their peers. </p>
<p>The hospital’s practices may turn out to be justifiable. But if they aren’t, there should be consequences: states and insurers should start withholding funding for the do-not-do procedure.</p>
<p>Our report provides a proof-of-concept for this approach. Many more do-not-do treatments can be measured, including those that should be performed, but not routinely (our report looks at a further three examples in this category). </p>
<p>For years there have been concerns that patients are getting the wrong treatment. Our Questionable Care report shows how to stop it.</p><img src="https://counter.theconversation.com/content/46089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To avoid ineffective treatments, we need a new way to identify and reduce questionable care. A new Grattan Institute report shows how to do it.Peter Breadon, Health Fellow, Grattan InstituteStephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/447152015-08-02T20:09:56Z2015-08-02T20:09:56ZWe’re overdosing on medicine – it’s time to embrace life’s uncertainty<figure><img src="https://images.theconversation.com/files/90266/original/image-20150730-22657-182ybv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/kokopinto/1744766359/in/photolist-7FDNYM-5ybjn2-3EbofB-9KY9Wj-qGDS6F-qq5RWC-qGufbZ-qEniU1-bWUa8e-cegvz5-ccbHNh-ccbGqw-ccbELY-bUPoWR-4tMDXt-8F6wcv-9WQ3CY-wkUQc-6rSdnG-92T4Ew-cuCykW-9uQTvm-9KVkMX-8FmLAq-6gGE2m-9SfJSh-8FiCsV-8FiCcT-8FmNns-8FmN2A-8FiBoc-8FiB7D-8FmMjY-8FmM4y-8FiAig-8FmLfW-8Fizvc-8FiyXX-8FiyHP-8FiyuD-8FiybB-8FixWc-8FixJB-8Fixu8-hrtzAQ-hrtza9-hrtyV1-hrsXnD-hrtyfy-hrsWuM">Kathea Pinto/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The more we learn about the problem of <a href="http://www.bmj.com/too-much-medicine">too much medicine</a> and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation. </p>
<p>But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.</p>
<h2>We’re all ill now</h2>
<p>A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, <a href="http://jama.jamanetwork.com/article.aspx?articleid=1148376">it’s estimated that</a> more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are <a href="http://www.aomrc.org.uk/dmdocuments/Promoting%20value%20FINAL.pdf">calling on doctors</a> to reduce all the wasteful things they do. And in Australia, the <a href="http://www.choosingwisely.org.au/">Choosing Wisely</a> campaign recently kicked off with lists of unnecessary and harmful health care.</p>
<p>Not only are we overusing pills and procedures, we’re creating <a href="http://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">even more problems with “overdiagnosis”</a> by labelling more and more healthy people with diseases that will never harm them.</p>
<p>Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities <a href="http://theconversation.com/whats-in-a-name-why-we-need-to-reconsider-the-word-cancer-16606">that are then treated as cancers</a>, even though they would never have caused anyone any symptoms if left undetected. </p>
<p>The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased. </p>
<p>The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are <a href="https://www.plos.org/wp-content/uploads/2013/05/plme-10-08-Moynihan.pdf">often being paid directly</a> by the companies that stand to benefit from turning millions more people into patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90270/original/image-20150730-25773-11oib0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/73381004@N00/59049213/in/photolist-6dDgT-as1b63-8VfiHg-pt1ZLD-4yvxmj-ayfZDT-57kwh9-bUSw6n-87uLL3-neJf4Y-uyrPfX-6wz4gq-4qJveT-nrmnqp-nHNFTA-nrm1Df-6NzzcH-f2o6hN-9oYe6J-ejVWBf-9KzFCs-4yNyBQ-5Z572r-n9uLQp-5Rpyvo-egsKjx-byjwTG-3wDidW-gi21pE-qRhU2a-fejVCN-3LBeAe-5XmMo3-4nJegS-qBxzPr-3THNtd-nEFYa-qG4X7s-6fNBQr-8mMsjZ-3TsZxy-iPkzVA-HqKUn-pVBG31-dguHFd-3WBzZh-71271F-4D7xVC-4Bradu-o6vq9">Javier ie/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.</p>
<h2>Fundamental shifts in thinking</h2>
<p>Indeed, <a href="http://www.bmj.com/content/349/bmj.g5702">intolerance of uncertainty</a> has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals. </p>
<p>More broadly, <a href="http://www.bmj.com/content/349/bmj.g6123">uncertainty is the basis</a> of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.</p>
<p>No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review. </p>
<p>The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process. </p>
<p>In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.</p>
<h2>Rays of hope</h2>
<p>Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90268/original/image-20150730-22647-4x3dcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The doctors who defined osteoporosis arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as ‘diseased’.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sandeepachetan/15258162923/">sandeepachetan.com travel photography/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine. </p>
<p>Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.</p>
<p>But, there are many positive signs of change within medicine. The <a href="http://www.choosingwisely.org.au/">Choosing Wisely</a> campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine. </p>
<p>A new approach called <a href="http://www.safetyandquality.gov.au/our-work/shared-decision-making/">shared decision making</a> is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called <a href="http://www.ncbi.nlm.nih.gov/pubmed/23062686">quaternary prevention</a> is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.</p>
<p>Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.</p>
<hr>
<p><em>Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a <a href="http://sydney.edu.au/sydney_ideas/lectures/2015/iona_heath.shtml">free public lecture</a> on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August 5.</em></p><img src="https://counter.theconversation.com/content/44715/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ray Moynihan is helping organise the Preventing Overdiagnosis conferences. He wrote this article in close collaboration with Dr Iona Heath.</span></em></p>By forgetting that medicine postpones death rather than saving lives, we persuade ourselves it might somehow keep extending our life and come to view death as a failure of medicine.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/409892015-04-30T20:48:21Z2015-04-30T20:48:21ZNo brain, no pain: it is in the mind, so test results can make it worse<figure><img src="https://images.theconversation.com/files/79904/original/image-20150430-6253-m9mndz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Your pain is in fact produced in your head and it will produce it more readily and more intensely if you have what you think is clear evidence that something is wrong.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/mislav-marohnic/5233928419">Mislav Marohnić/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>A common recommended “don’t” of the Choosing Wisely campaign in the <a href="http://www.choosingwisely.org/clinician-lists/american-association-neurological-surgeons-imaging-for-nonspecific-acute-low-back-pain/">United States</a>, <a href="http://www.choosingwiselycanada.org/recommendations/radiology/">Canada</a> and now <a href="http://www.nps.org.au/media-centre/media-releases/repository/choosing-wisely-australia-launching-in-2015">Australia</a> is getting imaging for non-specific back pain. The initiative, which identifies <a href="http://www.choosingwisely.org.au/recommendations">tests, treatment and procedures that have little benefit</a> but may lead to harm, is indeed wise in highlighting the dangers of such scanning.</p>
<p>The recommendation is based on several major studies – from <a href="http://link.springer.com/article/10.1007/s00586-007-0412-0">2007</a>, <a href="http://www.bmj.com/content/337/bmj.a171">2008</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1002/art.24853/full">2009</a>, <a href="http://link.springer.com/article/10.1007/s00586-010-1502-y">2010</a>, <a href="http://annals.org/article.aspx?articleID=746774&atab=7">2011</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008686.pub2/full">2013</a>. But while not imaging might be based on solid advice, it’s old advice. The recommendation has been around for years - ever since it was discovered that the state of your back MRI <a href="http://www.bodyinmind.org/spinal-mri-and-back-pain/">doesn’t relate very well</a> to <a href="http://www.nejm.org/doi/full/10.1056/NEJM199407143310201">whether or not you have back pain</a>.</p>
<h2>Still, they come…</h2>
<p>Nonetheless, the vast majority of people who turn up to participate in our research, two or three weeks into an episode of back pain, bring with them a bundle of MRIs tucked under their arm and a somewhat worried look on their face. </p>
<p>When we ask referrers about their almost ubiquitous MRI use, the most common answers tend to be “the pain was just so severe and the patient really wanted it”, “better to be safe than sorry”, “no harm in just excluding the nasty stuff”, and, the clanger - “lucky we did - there are some pretty major problems in there”. </p>
<p>And here is the rub. There’s no doubt that MRI is a really powerful tool. I am one of those who is gobsmacked by the detail these things provide and the magic of being able to see inside ourselves. I’m also pretty convinced that MRIs don’t carry physical risks. </p>
<p>So what’s problem? If people can afford it, or if the pain is really severe, it can’t do any harm, right?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79903/original/image-20150430-6258-17cojue.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pain is always created by your brain in an attempt to make you do something to protect your body.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jetheriot/6186786217">J E Theriot/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>One of my favourite phrases when it comes to the biological processes involved in pain is that we are “fearfully and wonderfully complex”. The key to understanding why an MRI might actually make your back pain worse is to understand first how back pain works. Indeed, how all pain works. </p>
<p>Pain is always – 100% of the time – created by your brain in an attempt to make you do something to protect your body. People right in the middle of an acute episode of back pain know this better than most - it’s a brutal, distressing and, at times, terrifying feeling that possesses you to desperately want to be rid of it. </p>
<p>It’s so compelling and so clearly “in your body”, that it can be difficult to believe that you <a href="http://www.ncbi.nlm.nih.gov/pubmed/9313643">don’t actually need a body part to have pain in it</a>. </p>
<p>But you do need a brain. No brain - no pain. </p>
<h2>Don’t believe me?</h2>
<p>You may not want to accept this – and many can’t at first bite – but it’s a comparatively small step to get there: any credible evidence of danger to your body will make pain worse and any credible evidence of safety to your body will make it better. </p>
<p>Because we haven’t yet identified everything that carries credible evidence of safety and danger, we lump those we don’t know about together and call them placebo (safety) and nocebo (danger) effects. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1083&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1083&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1083&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1360&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1360&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79906/original/image-20150430-6253-jmo0xj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1360&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Imaging will pick up the ‘kisses of time’ that have morphed your vertebrae and joints to better withstand the forces on them.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/katiecowden/2585721422">Katie Cowden/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The idea that the “placebo effect” or the “nocebo effect” are actual “things” is, in my view, <a href="http://www.bmj.com/content/336/7653/1086.2">a bit daft</a> because they’re really just umbrella terms for all the effects we haven’t identified yet. </p>
<p>As we discover that, for example, a clinician’s <a href="http://www.sciencedirect.com/science/article/pii/S0140673685909845?np=y">belief in the treatment they’re administering</a> affects its pain-relieving capacity, or that the pain-relieving effect of acupuncture <a href="http://theconversation.com/acupuncture-research-the-path-least-scientific-10273">depends more on whether you think you had acupuncture</a> than it does on whether you actually had it, the placebo “effect” seems to get smaller. It’s not the effect that’s getting smaller, we’re just understanding things better. But that’s a bit by-the-by for now.</p>
<p>The stakes in this idea of “credible evidence of danger” are very high when it comes to pain because of neuroplasticity - the wonderful adaptability of our brain and nervous system. Of course, it’s not just your brain that changes by itself, it’s your whole body, which is why I prefer to think of it as “<a href="http://www.bodyinmind.org/time-to-embrace-bioplasticity/">bioplasticity</a>”. </p>
<p>The point is that the more you play the piano, or football, the better you get at playing the piano, or football. So it follows that the more your whole system produces something like pain, the better it gets at producing pain.</p>
<h2>Try it out</h2>
<p>With this model of pain in mind, and a healthy respect for bioplasticity, let’s revisit that MRI you got after a week of brutal back pain. If you’re over 25 and half normal, then your MRI will show “stuff”. </p>
<p>It will pick up the “kisses of time” that have morphed your vertebrae and joints to better withstand the forces on them; it will pick up old minor injuries - perhaps you never knew you had - that have healed but left their trace just like a scar on your skin; it will pick up evidence that you’re no longer fresh out of the womb; and it will pick up many of your own idiosyncratic anatomical characteristics. Just like a photo of your face clearly shows you’re not the same as anyone else. </p>
<p>Unfortunately, when it comes to MRIs, these usual things are then given rather scary names, such as “broad-based disc bulge”, “degenerative changes” and <a href="http://en.wikipedia.org/wiki/Spondylolysis">spondylolysis</a>. </p>
<p>Credible evidence of danger? Sure sounds like it. And, because of your own fearfully and wonderfully complex system, your brain will store this information and quite possibly turn up the “need to protect” meter, just a bit. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=343&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=343&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=343&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=431&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=431&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79905/original/image-20150430-6233-1fap1aj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=431&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The pain-relieving effect of acupuncture depends more on whether you think you had acupuncture than on whether you actually had it.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/ggvic/2864310831">Victoria Garcia/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>So you dive into the challenge of finding the best strategy to “fix the MRI”, until eventually you come across someone with the apparent audacity to tell you, actually, those MRIs are pretty normal. Now you are livid, right? Are they telling me my pain is all in my head?!?! </p>
<p>Clearly, it is not - it is in your back. But, like it or not, if you are a human, your pain is in fact produced in your head and it will produce it more readily and more intensely if you have what you think is clear MRI evidence that something is wrong.</p>
<h2>Getting wise</h2>
<p>I have deliberately taken a provocative line here, but it is by no means outrageous. There are <a href="http://cercor.oxfordjournals.org/content/21/3/719.full">experimental data that clearly predict this scenario</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/20798647">big studies</a> that suggest getting an MRI early on is associated with poor outcome later. </p>
<p>So choose wisely when your back hurts; remember that even brutal back pain is rarely a sign of serious pathology and that it’s really, really common.</p>
<p>Remember that it will pass and it’s best to gradually increase your activity - respect your pain but don’t fear it. You should see a physiotherapist or a doctor because they know the important questions to ask and can coach you on the best road to recovery.</p>
<p>And remember – whether you think you are a tough nut or a bit of a softie – your brain considers <em>all</em> credible evidence of danger when it’s producing pain. If you do end up getting an MRI, expect to see the “kisses of time” and remember that they’re normal, even if they have scary names. Know that there’s no way of finding out when old injuries occurred, and the imaging will probably look just the same when your back no longer hurts.</p><img src="https://counter.theconversation.com/content/40989/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lorimer Moseley consults to health care providers in Australia, North America and Europe. He receives royalties for books about the prevention and treatment of pain and he receives payment for professional development seminars in Australia, North & South America, Asia and Europe. He receives project and fellowship funding support from the National Health & Medical Research Council of Australia. He is Chair of the PainAdelaide Stakeholders' Consortium.</span></em></p>People develop a long-term problem after an episode of back pain if they expect to not recover. Steps by the medical sector to avoid catatrophising back pain by not suggesting scans will help.Lorimer Moseley, Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.