14 tests you (probably) don’t need (part two)
Last week, I shared the first seven on my list of 14 medical tests you may not need. In this issue, I’ll be sharing some largely routine tests that may not be worth it—either due to expense, effectiveness, or the potential secondary effects of the procedures themselves. In this age of over-prescribing, over-diagnosing, and “CYA” medicine, it’s important to take the time to make informed decisions about your care.
Without further ado…
8. CT scans for kids with minor head injuries: We live in an over-protective and litigious society. When junior falls off the jungle gym and hits his head, the temptation is to get an immediate CT scan to rule out a life-threatening brain bleed. As a result, kids get numerous superfluous doses of powerful ionizing rays to a body part that’s developing fast at that age—the brain.
Research has indicated that that’s not inconsequential. There’s risk of significant cumulative damage, especially with multiple exposures to X-rays.
What’s the alternative? Pediatricians recommend that, for most minor head bumps, children be safely observed for changes in mental status over a period of hours after the injury. Vomiting, seizures, mental confusion or agitation, speech problems, severe headaches, coordination problems or difficulty staying awake are cardinal signs of a more serious underlying injury that may require imaging and urgent medical attention.
9. Routine dental x-rays at every dental checkup: No, you don’t need them every time, especially if you’re without new complaints and are there simply for a routine cleaning. They’re a money-making upsell for dentists and align nicely with insurance reimbursement under many plans.
But dental x-rays are not without value and shouldn’t be reflexively blown off. At certain intervals they do make sense because they can reveal the beginnings of problems not visible on inspection. And, if you’ve got multiple fillings or root canals, they might need more frequent evaluation with x-rays to assess their durability.
Besides, new technology enables safer imaging with lower exposure to x-rays, so much so that previous recommendations to drape dental patients in lead shields have pretty much gone by the boards.
10. Routine annual stress tests: Once a perk of lavish “executive” health plans, the ritual of the annual stress test has become passé.
Stress tests make sense when patients experience symptoms suggestive of underlying heart disease like chest pain, shortness of breath, or palpitations. Alternatively, doctors may want to rule out obstruction of blood vessels when imaging studies reveal an abundance of atherosclerotic plaque.
Occasionally, in an older or debilitated patient, a stress test might reveal heightened heart risk before a big operation. For example, my 80-year-old mother was scrubbed from hip replacement surgery when a stress test revealed she had severe circulatory problems that would have reduced the likelihood of her making it through a big operation.
False positives also occur, previously thought more common in women, but occurring in both sexes. With a frequency of up to 18%, the less likely it is that a person has underlying heart disease, the more likely an abnormal result on a stress test represents a red herring. More invasive tests, and sometimes overzealous stent placement can ensue.
11. Screening for H. pylori: Dr. Barry Marshall revolutionized gastroenterology in the 90s when he demonstrated that a bacteria could cause ulcers and even hike the risk for stomach cancer. This occasioned a paradigm shift, and a race to develop powerful combinations of antibiotics and acid-blockers to eradicate the culprit pathogen.
The problem is that a significant proportion of normal healthy individuals without gastrointestinal complaints harbor H. pylori; and while H. pylori may be implicated in stomach cancer, less than 3 per 100,000 individuals succumb to it each year.
For reference, in 2025 your risk of getting murdered was higher, at 4.1 per 100,000, the lowest it’s been since 1955. Smoking and alcohol use are far bigger risk factors for stomach cancer.
For some reason, medical reviews keep concluding that screening and treatment for H. pylori in the general population is “cost-effective”. But that doesn’t account for the widespread harms of repeated bouts of powerful antibiotics, which promote antibiotic resistance and irrevocably harm the microbiome, potentially fostering irritable bowel symptoms.
Plus, there’s evidence that even a “bad” bug like H. pylori has a protective role; while detrimental to stomach health, its impact on the esophagus appears to ward off GERD.
12. MRIs for back pain: Back pain is ubiquitous; it’s the evolutionary price we pay for standing upright to free our forelimbs to make tools. When stricken with back pain, the temptation is “take a look-see”, to pinpoint the source of the problem.
But in a recent review article in the BMJ, experts advise, “Do not routinely offer imaging for uncomplicated low back pain”.
They cite the following reasons:
- “Less than 5-10% of all low back pain is due to a specific underlying spinal pathology
- The remaining 90-95% has no indication of a serious cause and should be managed with conservative treatments such as advice and reassurance, exercise, physical therapy, chiropractic care, cognitive-behavioural therapy, or pain management
- Diagnostic triage based on clinical history and examination can help distinguish between non-specific or more serious low back pain
- Imaging may do more harm than good when serious conditions are not suspected and is likely to prolong recovery in patients with non-specific low back pain
- Patients’ primary concerns of whether their pain is caused by something serious and what they should do to aid recovery can be addressed by sound education and reassurance, without the need for imaging”
It’s important to remember that structure does not dictate function. In other words, people with messed up looking spines can sometimes be pain-free, while those with normal looking scans can be chronic sufferers.
This was famously demonstrated by an experiment in which experienced radiologists were given an assortment of spinal MRIs from people with and without back pain. They were blinded to the patients’ clinical histories and then asked to predict which patients had pain and which did not. They struck out miserably, misidentifying sufferers, with a success rate little better than a random card shuffle.
Past the age of 50, backs look bad when imaged. Spinal MRIs of even middle-aged adults universally show scoliosis, loss of disc cushioning, and osteoarthritic bone spurs. On seeing this, patients can be convinced that a “culprit lesion” is responsible for all their woes, and hope for recovery is dashed unless aggressive intervention is undertaken.
These maladaptive beliefs can take a profound psychological toll, and can become, according to psychosomatic medicine experts like the late Dr. John Sarno, author of “Healing Back Pain”, an impediment to recovery.
13. Daily labs in hospitalized patients: You go through life getting an occasional blood test, annually at your check up, or perhaps every few weeks if you have a problem. Then you check into a hospital, sometimes for a minor elective procedure, and suddenly everything changes; the vampires descend, siphoning multiple tubes of blood at your bedside every morning.
Sometimes blood tests are needed to monitor your precarious status. But more often, it’s just part of the routine of being hospitalized. Tradition, tradition!
But studies reveal that the practice is often misguided. In 60% of hospitalized patients, blood tests are ordered on a routine and repetitive basis without clinical indication. Patients already compromised due to illness, surgical blood loss, and food restrictions are literally exsanguinated by multiple superfluous blood draws, sometimes necessitating transfusions.
Not to mention the added expense the practice entails, the potential for injury to veins, sleep interruptions caused by 4 AM phlebotomies, and unnecessary investigations that irrelevant out-of-range findings can prompt.
When hospitalized, your Patient Bill of Rights explicitly entitles you or your advocate to demand an explanation for all procedures performed, as well as your right to refuse same. Question the rationale for all those blood tests.
14: Routine pre-operative ECG: You need an operation, but you’re otherwise healthy. It might be cataract surgery, a hernia repair, or a facelift. You require a pre-op physical to attest you can safely undergo surgery, but why are they insisting you get an ECG?
If you’re very elderly or have a history of heart problems, it makes sense. Or if the examining physician hears something funny when they press the stethoscope to your chest. Increasingly, health authorities have weighed in on this. They say:
“Upcoming surgery? You may not need any heart tests beforehand. Even in people with heart disease, presurgical cardiac testing should be the exception, not the rule.”
Why not accede to the test, that only takes a few minutes to perform and may be picked up by your insurance anyway? ECGs can detect heart problems that might place a patient at risk for a surgical complication, but they’re also rife with minor glitches that might be irrelevant to operative outcomes and could lead to a cascade of additional tests and specialist consults before they’re finally deemed insignificant. That can add expense and inconvenience, generate unnecessary patient anxiety, and delay important surgery.
While cataract surgery seems like a big deal because it involves the eyes and it’s often performed on seniors, the American Ophthalmological Association guidelines now discourage pre-op ECGs, except in high-risk cases.
FINAL NOTE: As with all consequential medical decisions, consult your health professional before making a choice. Read more about the American Board of Internal Medicine (ABIM) Foundation “Choosing Wisely” campaign to curb overuse and wasteful medical spending at choosingwisely.org