Posted by: notdeaddinosaur | April 15, 2012

Whose Choice is it Anyway?

There’s a welcome new program — some say “publicity stunt” — in town known as the “Choosing Wisely” campaign. Its ongoing mission: to identify medical tests, treatments, and procedures generally agreed to be unnecessary, yet still frequently recommended, prescribed, or performed. The campaign is a refreshingly cooperative exercise among various medical specialty societies. Nine different groups came up with five items each; several more groups are set to unveil their lists of  Five Things Physicians and Patients Should Question in the fall.

Unsurprisingly, there’s already been some pushback. My good friend Dr. Bob Centor calls out those who fall back on the “defensive medicine” canard:

Some physicians fall back on the lawyer excuse – I must do the test or else a lawyer can sue me.

This excuse is just an excuse.  The Choosing Wisely campaign focuses on the avoidance of clearly unnecessary testing.  Any physician who sees patients in the hospital sees many unnecessary tests.  Unnecessary tests cost us money, and not just for the test.  Test results beget more testing, and many unintended consequences.

Hear, hear!

There’s a guy named Davis Liu who doesn’t think it will work:

[T]he truth is doctors won’t likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses!

I call straw man, at least for the first two items on his list. Should I keep ordering immediate MRIs for acute back pain until every doctor washes his hands every time he sees a patient? If there were still a significant number of doctors actively opposing handwashing, or worse, ignorant of its importance, he may have a point. Antibiotic prescribing, though, involves another party: the patient.

I find that much of the pressure for unnecessary testing and treatment is coming from patients. Some of it is poor medical literacy coupled with a stunning degree of science ignorance. Some of it is old wives tales, misinformation, and peer pressure. (“All the other kids in daycare are on antibiotics for sinus infections.”) What this means for me is that this campaign is the greatest thing since they put pills in blister packs. At last I have public support from multiple medical societies, along with Consumer Reports (talk about your marketing powerhouses!) for things I’ve been trying to tell my patients for years.

No, you don’t need an MRI for a backache or a CT because you fainted. No, you don’t need antibiotics for your cold. No, we don’t have to do a million tests to figure out why you have hives. No, you don’t need an annual EKG or chest x-ray. Who says? Not just me anymore. At last there is a professionally based list of interventions explicitly labeled unnecessary.

Thanks for backing me up as I try to guide my patients toward better choices.

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Responses

  1. Sounds good to me. As a person who spend a fair amount of time seeing doctors for one thing and another, I have learned to question tests and actually work with the doctors to decide what is, or isn’t necessary. But it is not an easy task sometimes!

    By the way, Lucy, I bought and read your book a couple of years ago. It was quite good and I wish that Doctors like you were not such “dinosaurs”

  2. My orthopedic colleague tells me it’s not unusual for him to see somebody referred who’ve had an MRI for an ANKLE SPRAIN, for pity’s sake. . I find that the pressure for advanced imaging comes from: patients, for the reasons listed above (plus they’ve been on the internet and have already decided their diagnosis and treatment, never mind that they’re wrong), MDs who own imaging eqipment (sad but true) and midlevels (the dirty little secret is that they order a lot more advanced imaging because of their lack of training/knowlege/experience)..

  3. Hi Dr. Hornstein,
    I hope this Choosing Wisely campaign catches on! Someone just asked me to join the Obama campaign, but I’d rather be a part of a campaign like this! Given all the talk about health insurance reform and constitutional issues, no one seems to be taking on the problem of burgeoning medical costs head-on, or if they do they concentrate on stuff like hospital stays and surgical procedures, and not every day things like over-prescribed antibiotics and superfluous imaging studies. Apart from the hazards the risks they present to patients, they’re driving up costs and indirectly making insurance inaccessible to millions of people.
    By the way, I just discovered your blog and love it! I looked for your book in my local library and couldn’t find it, so I’m going to try to get it online.
    Thanks for your insightful postings,
    Joe P.

  4. Couldn’t agree more. As wonderful as it is that patients have such a wealth of information at their fingertips via the internet, rampant self-diagnosis has led to an increasingly paranoid patient population who now beg for more tests to rule out more diseases that were never worth testing for in the first place. I will admit to being somewhat surprised by the pushback, but I suppose it is the natural resistance that so many people have to any change…even change of the no-brainer variety.


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