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):
- 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.
- No DEXA scanning for bone mineral density until age 65 in women, one-time only, and age 70 in men.
- 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.]
- Don't perform Pap smears on women younger than 21.
- Don't order HPV (human papilloma virus) testing on women younger than 30.
- 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.
- Don't repeat colon cancer screening by any method (including stool blood testing) for 10 years after a negative colonoscopy in average-risk individuals.
- In the hospital don't order daily blood counts and chemistry panels in the face of clinical and lab stability.
- No echocardiograms or carotid ultrasounds for patients with simple syncope (faint).
- Don't order nuclear thyroid scans to evaluate thyroid nodules if thyroid function is normal.
- 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.]
- Don't perform ultrasound testing for boys with undescended testicles. [This is a new one for me.]
- 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.
parts per million of atmospheric carbon compatible with a familiar, sustainable planet Earth
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.