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Perspective | Less Is More

Investigations Before Examinations “This Is How We Practice Medicine Here”

Sunita Sah, MD, MBA, PhD1,2
[+] Author Affiliations
1McDonough School of Business, Georgetown University, Washington, DC
2Center for Ethics, Harvard University, Boston, Massachusetts
JAMA Intern Med. 2015;175(3):342-343. doi:10.1001/jamainternmed.2014.7549.
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“All new patients have an x-ray before seeing the doctor.” As a physician, I found this sentence baffling—I had been taught that the physician’s role is to first see a patient, take a detailed history, perform an examination, and consider the differential diagnoses. Only then could I consider the investigations required to get closer to a diagnosis and determine a treatment plan.

As a patient, however, my experience was different. Previously healthy with no medical problems, I began to feel a growing discomfort in my shoulder after a mandated vaccination. As the weeks progressed, the pain worsened, ultimately inhibiting me from performing routine tasks such as getting dressed. My primary care physician suggested steroid injections or a course of oral anti-inflammatories together with corticosteroids. Reluctant to have more injections, I opted for my physician’s suggestion of 1000 mg naproxen sodium daily while cautiously avoiding the oral steroids. As a small 160-cm woman, I am more sensitive than most to medications. In just 2 days, the naproxen gave me excruciating stomach pains—the treatment was worse than the shoulder pain. I berated myself for not questioning the physician about the high dosage. I stopped taking the medication and decided to try physical therapy.

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A different perspective on \"Less is more\".
Posted on March 31, 2015
Priscilla Park, MD
University of Wisconsin-Madison, Department of Psychiatry
Conflict of Interest: None Declared
In reading her piece, I believe Dr. Sah’s frustration with the orthopedic surgeon might be misplaced. The starting point of the problem appears to me that she went to a surgeon’s clinic for a non-surgical opinion and to get a physical therapy referral. This is understandable in that orthopedic surgeons are widely perceived as preferred doctors for musculoskeletal problems, but it remains that they are primarily concerned with evaluating people for surgery. To me, it seems that her visit to a specialist to get a referral that is available from primary care is the bigger issue for the \"Less is more\" lens, rather than the issue of x-rays before clinical evaluation.As a former surgical resident, we sometimes received clinic referrals to evaluate patients who did not want to consider surgical options, and these patients were often distressed to be offered the advice that they should undergo surgery. These visits often felt like wasted time and resources to both the patients and the surgeons. I have also been a trainee in orthopedic surgery clinics where people arrive without x-rays, and it does disrupt the evaluation process; presumably the purpose of the referral was to evaluate bones and joints for surgery, which is generally not possible based on clinical examination alone. To that end, her surgeon’s confusion about her expectations is understandable to me. I also think the title quote about the practice of medicine is open to interpretation; I read his remark as referring to the way x-rays are obtained for his surgical clinic, rather than referring generally to the system of medical care in the US.In reading the accompanying editorial, there is the acknowledgment that certain specialties will need imaging prior to consultation, and I would argue that a referral to an orthopedic surgeon falls into this category as well. A first step of exploring appropriate non-surgical options in primary care for patients who are not at the stage of needing surgery, thus avoiding an expensive and unnecessary surgical referral with accompanying unnecessary imaging, would be the better fit for the “Less is more” approach, in my opinion.
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