John A. Patterson MD, MSPH, FAAFP
“First, do no harm”
This Hippocratic ideal guides the practice of medicine. Both physicians and patients share this goal of good medicine. This means using appropriate tests to determine a correct diagnosis, using appropriate treatment for the diagnosed condition, avoiding harm caused by testing and treatment, and doing all this as economically as possible.
Both physicians and patients have embraced modern diagnostic technology and modern medical treatments in part because they have helped relieve tremendous suffering and saved countless lives. But unsustainable cost increases have led to our need to control health care spending by choosing wisely how to use the tools of modern medicine. Unavoidable and inevitable side effects to medications and testing have also caused tragic harm to patients. This has led several major medical organizations to consider ways for medicine to be practiced even more wisely, humanely, safely and economically.
The Choosing Wisely Campaign targets medical tests and treatments that are unnecessary under certain conditions and can also cause serious harm. These tests and treatments that are considered safe under most circumstances but may lead to further testing and treatment which can increase cost and the potential for patient harm. To encourage conversations between patients and doctors, participating medical groups have created recommendations, based on best available medical evidence, to help doctors and patients make wise decisions about the most appropriate care for an individual patient’s individual needs.
So far, nine medical specialty groups have agreed on “Five Things Physicians and Patients Should Question” for their own medical specialty. These groups are- the American Academy of Allergy, Asthma and Immunology; the American Academy of Family Physicians; the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology. Other medical organizations are in the process of adding their specialty’s list of five.
The initial scientific paper announcing the Choosing Wisely Campaign appeared as part of the “Less is More” series in the Archives of Internal Medicine, one of the family of scholarly medical journals published by the American Medical Association.
With the Choosing Wisely Campaign, these medical groups seek to increase public health and decrease patient harm by educating both physicians and consumers about overused diagnostic and therapeutic interventions.
Below is a partial list of recommendations for adults-
1) X ray, CAT scan and MRI for low back pain are unnecessary in the first 6 weeks unless there are certain red flags on examination.
2) Antibiotics are unnecessary for mild to moderate sinus infections.
3) Routine annual EKGs and other cardiac screening are unnecessary for low-risk patients who have no cardiac symptoms.
4) Pap smears are unnecessary for women under age 21 or women who have had a hysterectomy, unless they still have a cervix or their hysterectomy was performed for cancer.
5) DEXA (BMD) scans to screen for osteoporosis are unnecessary in women under age 65 and men under age 70 unless specific risk factors are present.
6) Healthy adults do not need routine blood and urine testing, although cholesterol screening may be indicated for some people and those with high blood pressure should be screened for diabetes.
7) If statins are chosen to initiate therapy to lower cholesterol or triglycerides, generic drugs should be used before more expensive brand name drugs.
This is a partial list of recommendations for children-
1) Antibiotics are not necessary for sore throat/tonsillitis unless there is a positive test for streptococcal infection.
2) An X ray, CAT scan or MRI is unnecessary after minor head injury unless there has been loss of consciousness or certain symptoms and physical findings suggest increased risk of serious injury.
3) Middle ear infections (even those with effusion or ‘fluid behind the ear drum’) can be treated by the primary care provider unless certain red flags are present on examination. If an uncomplicated infection does not resolve within 3 months, referral to an ear specialist may be indicated.
4) It is not necessary, and may be harmful, for children to use over-the-counter cough and cold medication.
5) Overuse of both oral and inhaled medications for asthma can be harmful and can be prevented by the regular use of a steroid (‘cortisone’) inhaler. A threshold for beginning such inhalers is either 4 wheezing episodes, or 2 episodes requiring oral steroids, within 6 months.
Frank conversations about these interventions can help patients and their providers contain health care costs, avoid causing harm and make rational decisions based on the best available medical evidence of safety and effectiveness.
So that we can all “do no harm”, Consumer Reports Health is partnering with these medical societies to make information about the Choosing Wisely Campaign available to the general public. You can find out more at either- http://choosingwisely.org or http://consumerhealthchoices.org/campaigns/choosing-wisely
About the Author-
Dr Patterson is past president of the Kentucky Academy of Family Physicians and is board certified in family medicine and integrative holistic medicine. He is on the family practice faculty at the University of Kentucky College of Medicine and the University of Louisville School of Medicine, Saybrook University’s School of Mind Body Medicine (San Francisco) and the Center for Mind Body Medicine (Washington, DC). He operates the Mind Body Studio in Lexington, where he offers integrative medicine consultations. He can be reached through his website at www.mindbodystudio.org.