By Richard Young, M.D.
“Every admitted patient should have a chest X-ray and a VDRL,” said one of my Type A personality internal medicine attending physicians during residency. The year was 1990 and this attitude was shared by a few other knowledgeable physicians at the time, though others questioned the practice and were more flexible in their medical decision-making. I would venture to guess that few family physicians or internists practice this way in 2012, but the practice is not completely dead.
A lot has changed since 1990. The total cost of U.S. health care was $724 billion and consumed 12.5 percent of the gross domestic product.1 In 2012, the total cost of U.S. health care is estimated to be $2.8 trillion and will consume 17.6 percent of GDP.2 This health care inflationary trend has continued unabated for the last 50 years.
There are other reasons besides cost considerations to avoid unnecessary tests, such as the harms caused by further work-ups of first-test abnormalities that are later discovered to be false positives. Recently, the American Board of Internal Medicine Foundation challenged specialty societies to propose five patient care practices that should not be routine. They named this initiative “Choosing Wisely,” and nine medical societies participated. The complete lists of recommendations and their rationales are available at www.choosingwisely.org.
The American Academy of Family Physicians submitted the following five recommendations:
- Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
- Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
- Don’t use dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
- Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
- Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
Other societies wrote recommendations that impact family medicine. From the American College of Physicians (with duplicates of the AAFP recommendations removed):
- In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
- In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
- Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
From the nephrologists:
- Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
From the cardiologists:
- Don’t perform stress cardiac imaging or advanced non-invasive imaging as a preoperative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
- Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
From the radiologists:
- Don’t do imaging for uncomplicated headache.
- Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
- Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
- Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.
Changes in physicians’ habits are driven by many factors, including the fear of lawsuits. While these lists do not provide ironclad protection in the event of a rare patient outcome, they are clear statements from the major medical societies on tests and treatments that should be considered unnecessary by everyone.
Recent projections estimate that if major changes are not implemented to reduce the growth of U.S. health care costs, then the cost of a family health insurance premium will equal household income by 2033.3 Even under optimistic assumptions of the Affordable Care Act, this crossover year is only pushed back four years to 2037.
For physicians to be part of the solution to this unsustainable trajectory, they must be willing to let go of outdated practices for both cost and quality concerns. They need to move away from a general attitude of “just do it,” to “when in doubt, don’t.” The Choosing Wisely campaign is a great place to start this journey.
- Centers for Medicare and Medicaid Services. National Health Expenditures Aggregate. https://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf. Accessed May 30, 2011.
- Centers for Medicare and Medicaid Services. National Health Expenditures and Selected Economic Indicators, Levels and Annual Percent Change: Calendar Years 2005-2020. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads//proj2010.pdf. Accessed May 21, 2012.
- Young RA, DeVoe JE. Who will have health insurance in the future? An updated projection. Ann Fam Med. Mar-Apr 2012;10(2):156-162.