Now there are 135.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
Organised 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
People and their
"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 emphasise 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.
Thousands chose the
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
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. 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
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 sympathyse 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
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
X-ray screening for
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 DEFCONOther "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
"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.
If doctors adopt the recommendations of their specialty,
doctor visits for some chronic diseases would be very different. Patients with
recurrent headaches would not get EEGs (electroencephalography); they don't
improve outcomes. And rheumatologists would not use MRIs to monitor joints in
patients with rheumatoid arthritis; a clinical assessment is just as good.
Women received different
Women in particular would get quite different care. Those
younger than 21 and those who have had a hysterectomy for anything but cancer
should not get Pap smears at all, experts say. Other women should get the tests
every three years, not annually, between ages 30 to 65."We did a great job
training everyone, women as well as doctors, to get an annual Pap smear,"
said ACOG's Lawrence.
"Now we have to untrain them."That won't be easy.
The first Choosing Wisely list of 45 procedures was released last April, too
recently for there to be hard data on whether they're changing practice. But some
of these battles have been fought for years, with scant success.
ACOG has been trying to reduce the rate of elective
cesareans for decades, and its Choosing Wisely list tells obstetricians not to
schedule elective cesareans or induce labor before week 39. The rate of
cesareans in the United States was 33% of deliveries in 2009, up from 21% in
1996, federal data show.
The experience of Intermountain Healthcare, a group of
hospitals and clinics in Utah, suggests why. The nonprofit recently cut its
rate of inappropriate labor inductions and cesareans from 28% of births to 2%.
That saved Utah $50
million a year in healthcare spending, mostly by reducing use of the neonatal
intensive care unit, where many babies delivered in these ways wind up. But
Intermountain also lost $9 million in annual billings."In our
fee-for-service healthcare system," said Consumer Reports' Santa,
"poor clinical outcomes for babies improve revenue streams for
hospitals," and better care can reduce revenues.
by signing up to Choosing Wisely
Many business groups have signed on to Choosing Wisely,
hoping it will reduce soaring healthcare costs. For instance, the National
Business Coalition on Health, with 7 000 employer members, and the National
Business Group on Health, representing Fortune 500 companies and other large
employers, are distributing to their members educational material developed by
Consumer Reports, a partner in Choosing Wisely.
They are careful to emphasise that the advice comes from
doctors. "If employers say you shouldn't have all these tests or
procedures, it'll inevitably be seen as 'my employer doesn't want to spend the
money to cover them,'" said Helen Darling, president of the Business
The pages and pages of lists, available at For one thing,
there is no regulatory requirement that physicians prove a new procedure helps
patients, as drug makers must do before selling a new pharmaceutical.
For another, "Americans want the latest, newest
thing," said Dr Howard Brody of the University of Texas Medical Branch,
whose 2010 challenge to physicians to identify worthless tests and treatments
inspired Choosing Wisely.
"Technological enthusiasm on the part of physicians and
the general public makes them willing to adopt new things without rigorous
testing. Only years later, and only if studies are done, do we see that it's no