Just say don't: Doctors question routine tests and treatments
Doctor (Joe Raedle, Getty Images)
That's how many medical tests, treatments and other procedures - many used for decades - physicians have now identified as almost always unnecessary and often harmful, and which doctors and patients should therefore avoid or at least seriously question.
The lists of procedures, released on Thursday by the professional societies of 17 medical specialties ranging from neurology and ophthalmology to thoracic surgery, are part of a campaign called Choosing Wisely. Organized by the American Board of Internal Medicine's foundation, it aims to get doctors to stop performing useless procedures and spread the word to patients that some don't help and might hurt.
"Americans' view of healthcare is that more is better," said Dr Glenn Stream, a family physician in Spokane, Washington, and board chairman of the American Academy of Family Physicians, which has identified 10 unnecessary procedures. "But there are a lot of things that are done frequently but don't contribute to people's health and may be harmful."
In a particular case, even a procedure that provides no benefit to the vast majority of people might be appropriate. That's why the physicians emphasize that they are only advising against routine use of the usually unnecessary tests and therapies.
For instance, the American Academy of Pediatrics says physicians "should question" CT scans for kids' minor head injuries or abdominal pains, which usually don't improve diagnoses and raise the risk of cancer. But if doctors suspect something unusual, a scan may be in order.
For the most part, the medical specialty groups did not consider cost when they made their lists. If their advice is followed, however, it would save billions of dollars a year in wasteful spending, said Dr John Santa, director of Consumer Reports' Health Ratings Center and a partner in Choosing Wisely.
One large medical group with 300,000 patients, Santa said, calculated that following the Choosing Wisely advice on just two procedures, superfluous EKGs (electrocardiograms) and bone-density scans, would reduce its billings by $1 million a year. Nationally, that translates into some $1 billion in savings.
The medical specialty groups each came up with five procedures to "question," but most of the items begin with an emphatic "don't." The targeted procedures range from the common to the esoteric.
RETHINKING SWIMMER'S EAR, PRE-OP TESTS
Other specialists say no cough and cold medications for kids under 4, no oral antibiotics for acute infections of the ear canal ("swimmer's ear") and no use of drugs to keep blood sugar in older adults with type 2 diabetes within tight limits. There is no evidence that tight "glycemic control" - which is widely practiced - is beneficial, said the American Geriatrics Society. Instead, the diabetes drugs used to achieve tight control increase mortality, and tight control itself can cause low blood sugar.
Some recommendations, if widely adopted, would mean significant changes in patient care. The geriatricians, for example, recommend against feeding tubes in patients with advanced dementia. The tubes hurt and cause problems; carefully feeding the patient is better.
Anyone who has ever had surgery while in generally good health can sympathize with the recommendation against multiple pre-op tests: Ophthalmologists now advise against EKGs and blood glucose measurements before eye surgery, except for patients with heart disease or diabetes.
Physicians recommend against many procedures patients have come to expect, including imaging for low back pain (unless it has lasted more than six weeks) and any cardiac screening, including EKGs, in patients without heart symptoms.
The widely used "DEXA" X-ray screening for osteoporosis landed in rheumatologists' crosshairs. It should not be done more than once every two years, they advise, because changes in bone density over shorter periods are typically less than the machines' measurement error, which can cause women to think they're losing bone mass when they're not.
RETREAT FROM DEFCON
Other "don't's" may be hard sells to patients for whom any abnormality requires medicine's version of Defcon 1.
Take a finding of abnormal cells in the cervix. The American College of Obstetricians and Gynecologists (ACOG) says not to treat women whose Pap test for cervical cancer finds dysplasia unless the abnormalities persist for two years.
"Treatment damages the cervix and raises the risk in subsequent pregnancies," said ACOG Executive Vice President Dr Hal Lawrence. The abnormal cells are almost always the result of a viral infection that the body clears on its own, but women who think they mean impending cervical cancer will need convincing.