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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.
 
 

4 comments:

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