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Thursday, April 4, 2013



A VIEW FROM THE OFFICE






THE COMPLETE 'CHOOSING WISELY' GUIDELINES
 
THE BEST WHAT-NOT-TO-DO's IN MEDICINE:  We are at the threshold of a new era in medicine that really began with an article in Annals of Internal Medicine(1), which I reviewed in the Jan 12th issue of the Journal of the FP Revolution in 2012. This started a brand new movement in medicine which has now gained substantial momentum. A large number of generalist and specialist societies have now identified and endorse a core set of test, evaluations, and practices that no longer ought to be done. [Actually we should never have been doing them, but we're slow learners making progress.] Since they are posted in the Internet in obscure locations (2), many of us have never seen them. Therefore, I am going to just provide a graphic to illustrate each of them with no other commentary in this issue. Read 'em and learn 'em. They're great!

Here's the main point: There is almost universal consensus among medical experts (including myself) that the medical procedures listed below SHOULD NOT BE DONE. If your doctor is recommending any of them, ask him/her, "Why?"  Or, equally acceptable, just say NO!

      Also very valuable for consumers are the consumer information sheets that accompany each one of these guidelines. There is a sample at the bottom of this page. The whole set can be found at this link:  http://www.choosingwisely.org/doctor-patient-lists/
 
        My favorites are (a Baker's Dozen):
  1. No routine pre-operative lab tests in average risk patients: not chest x-rays, ECGs, or chemistries or coagulation tests. Let's face it. Hospitals and surgicenters want these only for revenue production.
  2. No DEXA scanning for bone mineral density until age 65 in women, one-time only, and age 70 in men.
  3. No routine annual cholesterol panel in patients not on a special diet or drug therapy. [Note: This puts us at odds with many so-called expert guidelines that govern organizations like Kaiser, Community Health Centers, etc. Once every 5 years is enough for people without risk factors or disease.]
  4. Don't perform Pap smears on women younger than 21.
  5. Don't order HPV (human papilloma virus) testing on women younger than 30.
  6. Don't order carotid ultrasounds as screening for asymptomatic patients. [The corollary of this is, Don't auscultate for bruits (a harsh sound from irregular blood flow) on routine exams. A finding of a bruit will make your doctor really, really want to order an ultrasound. Don't let him/her! The USPSTF specifically 'recommends against' it because known harms exceed known benefits.
  7. Don't repeat colon cancer screening by any method (including stool blood testing) for 10 years after a negative colonoscopy in average-risk individuals.
  8. In the hospital don't order daily blood counts and chemistry panels in the face of clinical and lab stability.
  9. No echocardiograms or carotid ultrasounds for patients with simple syncope (faint).
  10. Don't order nuclear thyroid scans to evaluate thyroid nodules if thyroid function is normal.
  11. Don't prescribe cough and cold medications for children < 4 years of age. [Their parents can always do this, but physicians shouldn't be doing it.]
  12. Don't perform ultrasound testing for boys with undescended testicles. [This is a new one for me.]
  13. Don't order special testing for clotting disorders when patient presents with a first episode of a venous leg clot with a known cause (such as a recent fall, fracture, surgery, or other trauma). Don't re-image a venous leg clot in the absence of a clinical change.
    Go ahead and pick your own favorites from the lists below. [...and let your friends know!]
 
 
 
 
 
 
 
 
 
 
 




























        The Choosing Wisely website also has nice accompany patient education handouts for consumers. A sample for GERD appears below.








   350
parts per million of atmospheric carbon compatible with a familiar, sustainable planet Earth
 
 
 
REFERENCES:
 
1. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med 2012; 156: 147-9. EDITORIAL: Laine C. High-value testing begins with a few simple questions. Ann Intern Med 2012; 156: 162-3.
 
2. The ABIM Choosing Wisely website: http://www.choosingwisely.org/doctor-patient-lists/
 
 
 
 
 
 
Article retrieval tips: To find an article in PubMed simply enter the PMID number into the search field. Where a 'doi' heading is listed, you can insert the doi information into a Google search and retrieve the article.
 
 

7 comments:

  1. My Husband divorce me for no reason, this is how i get him back today because i really love him so much,I'm very excited sharing this amazing testimony, My name is Becky Miller, from USA a banker by Profession. I'm happily married to a lovely and caring husband ,with three kids. A very big problem occurred in my family seven months ago,between me and my husband .so terrible that he took the case to court for a divorce.he said that he never wanted to stay with me again,and that he didn't love me anymore.So he packed out of the house and made me and my children passed through severe pain. I tried all my possible means to get him back,after much begging,but all to no avail.and he confirmed it that he has made his decision,and he never wanted to see me again. So on one evening,as i was coming back from work,i met an old friend of mine who asked of my husband .So i explained every thing to him,so he told me that the only way i can get my husband back,is to visit a spell caster,because it has really worked for him too.So i never believed in spell,but i had no other choice,than to follow his advice. Then he gave me the email address of the spell caster whom he visited.{bravespellcaster@gmail.com}. So the next morning,i sent a mail to the address he gave to me,and the spell caster assured me that i will get my husband back the next day.What an amazing statement!! I never believed,so he spoke with me,and told me everything that i need to do. Then the next morning, So surprisingly, my husband who didn't call me for the past 9 months,gave me a call to inform me that he was coming back.So Amazing!! So that was how he came back that same day,with lots of love and joy,and he apologized for his mistake,and for the pain he caused me and my children. Then from that day,our relationship was now stronger than how it were before,by the help of a spell caster. So, i will advice you out there to kindly visit the same website { http://lovespelldrbrave.weebly.com/. } if you have any problem contact Dr Brave ,{ bravespellcaster@gmail.com }, thanks you Dr Brave, i will always be testifying about your good work, and for any questions call me on +1(575) 779-6197.

    ReplyDelete
  2. My Husband divorce me for no reason, this is how i get him back today because i really love him so much,I'm very excited sharing this amazing testimony, My name is Becky Miller, from USA a banker by Profession. I'm happily married to a lovely and caring husband ,with three kids. A very big problem occurred in my family seven months ago,between me and my husband .so terrible that he took the case to court for a divorce.he said that he never wanted to stay with me again,and that he didn't love me anymore.So he packed out of the house and made me and my children passed through severe pain. I tried all my possible means to get him back,after much begging,but all to no avail.and he confirmed it that he has made his decision,and he never wanted to see me again. So on one evening,as i was coming back from work,i met an old friend of mine who asked of my husband .So i explained every thing to him,so he told me that the only way i can get my husband back,is to visit a spell caster,because it has really worked for him too.So i never believed in spell,but i had no other choice,than to follow his advice. Then he gave me the email address of the spell caster whom he visited.{bravespellcaster@gmail.com}. So the next morning,i sent a mail to the address he gave to me,and the spell caster assured me that i will get my husband back the next day.What an amazing statement!! I never believed,so he spoke with me,and told me everything that i need to do. Then the next morning, So surprisingly, my husband who didn't call me for the past 9 months,gave me a call to inform me that he was coming back.So Amazing!! So that was how he came back that same day,with lots of love and joy,and he apologized for his mistake,and for the pain he caused me and my children. Then from that day,our relationship was now stronger than how it were before,by the help of a spell caster. So, i will advice you out there to kindly visit the same website { http://lovespelldrbrave.weebly.com/. } if you have any problem contact Dr Brave ,{ bravespellcaster@gmail.com }, thanks you Dr Brave, i will always be testifying about your good work, and for any questions call me on +1(575) 779-6197.

    ReplyDelete
  3. A broken heart can be one of the most painful things to heal from and can take a very long time to heal. During these times it can feel like the whole world could light up in flames and it still couldn't compare to the pain inside.

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  5. My life is back!!! After 3 years of broken marriage, my husband left me with three kids. I felt like my life was about to end i almost committed suicide. Thanks to Doctor Ehimen who i met online as i was browsing through the internet, I came across allot of testimonies about him. Some people testified that he brought their Ex lover back, he restores womb, stop divorces, cure cancer and other sickness. I also come across one particular testimony by Sarah who lives in Finland saying how he brought back her Ex husband after 3 years of divorce. After reading all these, I decided to give it a try. I contacted him and explained my problem to him. In just 12 to 16 hours, my husband came back to me pleading and we resolved our issues and we are even happier than before. Doctor Ehimen is really gifted and i will not stop publishing about his good works. If you have any problem, contact him now for he might be the answer to your problems. Email: ( Doctorehimenspelltemple@hotmail.com ).

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