How much medical care is enough?

A recent British study of 3,800 whiplash sufferers compared “usual care” at 15 hospitals with “costly, intensive treatment.” The results indicated that treatment outcomes were the same in both groups.

Doctor Sarah Lamb, and fellow investigators of the University of Warwick, detected an identical level of recovery at eight and 12 months, although patients treated more aggressively with physical therapy sessions felt better at four months after the injury. Lamb, interviewed for HealthDay News, concludes, “Emergency departments should continue to provide usual care for whiplash injuries together with a single follow-up physiotherapy advice session for persisting symptoms.”

American medical experts are already citing the British study as justification for a minimalist approach, with little physical therapy, for whiplash injuries.

The whiplash data is in a sense consistent with similar observations with respect to a host of conditions, including low back pain, the common cold, and simple aches and pains. No matter what the doctor does, the human body usually will eventually heal itself.

Nonetheless, as a practicing physician, I find this kind of study a bit troubling. I have no quarrel with the observations or conclusions. Rather, I know that “gatekeepers” and “utilization review” employees tend to use such data as justification for “denying” referrals in cases in which specialized treatment, such as physical therapy, may play a role. The usual process involves citing specific medical studies or guidelines in a rigid manner, with no appreciation for the possibility that a given patient may have special needs.

In many cases, as referral for services is not overtly denied, but rather endlessly delayed. The referring doctor is told to re-submit the referral request with more information. The cycle repeats itself. Yet more information is required. Eventually, the treatment may or may not be realized, depending upon how persistent the referring doctor is.

Indeed, sometimes less is more in medical therapy. For example, it is prudent to avoid the use of antibiotics in most viral respiratory infections. Low back pain sufferers typically get better without surgery or prolonged physical therapy. Whiplash pain will usually resolve with local cold or heat, accompanied by a brief course of anti-inflammatory medication.

Moreover, as health care costs are increasingly reigned in, we may all find ourselves relying more and more upon our own health care recovery strategies. As an example, exercising and avoiding smoking can diminish back pain.

There are, however, specific situations in which a “routine” muscular strain requires more than “routine” care.

I recall seeing a patient who was shuttled from clinic to clinic with neck pain, only to be eventually diagnosed with a bone infection of the cervical spine that was life-threatening. So-called “red flags” may alert a clinician to a severe underlying problem that is not immediately apparent. Classical “red flags” include high fever, night pain, weight loss and unrelenting pain. Especially when neck or back pain occurs in elderly patients, these warning signs deserve careful consideration.

What if your “routine” condition is not taken seriously by your provider network?

In today’s era of managed care, insisting upon care may be an uphill struggle. Discussing your concerns directly with your physician is the best initial approach, if you can reach your doctor. If that does not allay your concerns, recall that many clinics and nursing homes now provide access to an ombudsman, a respected third party who can advocate on your behalf.

I have noticed over the years that patients with concerned relatives seem to do better than more isolated persons. One reason may be health-access advocacy, by concerned spouses, children and parents. Routine health care is generally fine, but sometimes a patient needs treatment beyond the routine level.

Scott Anderson, M.D., Ph.D. (stamdphd@comcast.net) is Clinical Professor of Medicine, Division of Rheumatology, UC Davis. This column is informational, and does not constitute medical advice.