Doctors sometimes order tests, write prescriptions and recommend treatments that they know are unnecessary.
Why? Because there is a “better safe than sorry” attitude that prevails, often fuelled by a fear of legal action and by ailing patients who insist on some concrete action. The result is a lot of over-treatment, wasted health-care dollars and a fair bit of physical harm.
So, last year, the American Board of Internal Medicine Foundation, in conjunction with nine big American physician organizations and the magazine Consumer Reports, launched a campaign called Choosing Wisely. The idea was to have doctors and patients talk about choosing care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.
As part of the campaign, specialist medical groups were asked to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed.
One enthusiastic participant in the exercise has been the American Academy of Family Physicians. The following are the AAFP’s recommendations:
1. Don’t do imaging for low back pain in the first six weeks unless red flags are present. Low back pain is one of the top reasons for visits to family physicians, but imaging – CT scan or MRI – does not improve outcomes for most people.
2. Don’t routinely prescribe antibiotics for mild to moderate sinusitis unless symptoms last for more than seven days. Most sinus infections are caused by viral infections and clear up on their own (antibiotics work only for bacterial infections). Over-prescription has also fuelled antibiotic resistance, a major public health problem.
3. Don’t use dual-energy x-ray absorptiometry screening for osteoporosis in women under 65 or men under 70 with no risk factors. Bone-density tests are of dubious value at any age, but they definitely are not cost-effective in younger people.
4. Don’t order annual electrocardiograms or any other cardiac screening for low-risk patients. There is little evidence that testing patients with no symptoms and a low risk for coronary heart disease improves health outcomes. False-positive test results are likely to lead to harm.
5. Don’t perform Pap tests on women younger than 21 or those who have had a hysterectomy for reasons other than cancer. In Canada, it is now recommended that Pap tests begin at age 25 and follow at three-year intervals.
6. Don’t schedule elective inductions of labour or Caesarean sections on pregnant women before 39 weeks. There is no medical reason to induce delivery early, and doing so is associated with a host of health problems.
7. Avoid elective inductions of labour between 39 and 41 weeks unless the cervix is deemed favourable. Labour should start on its own regardless of the weeks of gestation.
8. Don’t screen for carotid artery stenosis (narrowing of the arteries) in adult patients with no symptoms. Doing so can lead to unnecessary surgery, and hikes the risk of stroke.
9. Don’t screen women older than 65 for cervical cancer if they have had adequate prior screening. Cervical cancer is rare in this age group, so the test offers little benefit.
10. Don’t screen women younger than 30 for cervical cancer with HPV testing alone or in combination with cytology. HPV testing is now being done instead of Pap tests in some cases because it is more precise, but it is still not useful in younger women.
11. Don’t prescribe antibiotics for otitis media in children aged 2 to 12 with non-severe symptoms. Doctors should treat earache symptoms and observe for 72 hours before prescribing antibiotics.
12. Don’t perform voiding cystourethrogram routinely for a child’s first urinary tract infection with fever. This procedure involves radiation and there is no harm in waiting for a second UTI in the few children who will actually benefit.
13. Don’t routinely screen for prostate cancer using the prostate-specific antigen test or digital rectal exam. The evidence shows that routine testing results in more harm than good.
14. Don’t screen adolescents for scoliosis. Routine screening of teens with no symptoms of this spinal condition does not offer any benefit and can cause psychological harm.
15. Don’t require a pelvic exam or other physical exam before prescribing oral contraceptives. There is no reason to do a pelvic or breast exam before prescribing the Pill.
There will be those who are outraged with some of these recommendations. That’s because every one of the tests has some potential benefits to some patients (and, of course, some potential harm).
There are plenty of anecdotes about people’s lives “being saved” by drugs and tests and procedures. But those stories, however compelling, are not evidence, nor should they be the basis for policy-making.
The AAFP is not suggesting abandoning those 15 procedures. On the contrary, Choosing Wisely is all about being judicious.
Over-treatment is a serious problem in the U.S. and in Canada too: Performing unnecessary tests, prescribing drugs inappropriately are not benign activities. They have the potential to cause harm, and they waste in addition to wasting money.
Let’s not forget that good medical care is just as much about what we don’t do as what we do.