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Applause, Applause!

Posted by John McDonough  April 9, 2012 09:37 PM

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It's time for me to say something nice about physicians, and the organized kind in particular.

For many years, I've noticed that organized groups/stakeholders/associations have an almost impossible taking public positions that violate their economic self-interest. It happens so rarely, at least in the health space, I can count on one hand the number of notable exceptions I have encountered, for example:

  • Dentists who support water fluoridation;
  • Pediatricians who support vaccination;
  • The Massachusetts Medical Society in the 1990s who led a first-in-the-nation effort to make physician liability records available online.

Perhaps you can think of others. They are few and far between. Individuals, even as members of groups, can part company with the herd. It's just devilishly hard for organizations themselves to do so because self-interest is so engrained in their DNA.

This makes it all the more noteworthy that last week nine U.S. physician specialty societies representing 374,000 physicians released a total of 45 recommendations (5 each) for common medical treatments that should not be done commonly by their members on/to patients. For more information on the campaign, check out the website Choosingwisely.org organized by the American Board of Internal Medicine.

These lists are specific and evidence-based recommendations "physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation."

Most journalistic accounts of this development list only a handful of the recommendations. As a salute to the nine groups, I include the entire list of 45 in this post:

American Academy of Allergy, Asthma & Immunology

  • Don't perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
  • Don't order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
  • Don't routinely do diagnostic testing in patients with chronic urticaria.
  • Don't recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.
  • Don't diagnose or manage asthma without spirometry.

American Academy of Family Physicians

  • 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.

American College of Cardiology

  • Don't perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
  • Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
  • Don't perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative 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.
  • Don't perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

American College of Physicians

  • Don't obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
  • Don't obtain imaging studies in patients with non-specific low back pain.
  • 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 thromboembo- lism (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.

American College of Radiology

  • Don't do imaging for uncomplicated headache.
  • Don't image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
  • Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
  • 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 cyst.

American Gastroenterological Association

  • For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
  • Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
  • Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high- grade dysplasia, completely removed via a high-quality colonoscopy.
  • For a patient who is diagnosed with Barrett's esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.
  • For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

American Society of Clinical Oncology

  • Don't use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti- cancer treatment.
  • Don't perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.
  • Don't perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
  • Don't perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
  • Don't use white cell stimulating factors for primary prevention of febrile neutropenia for
    patients with less than 20 percent risk for this complication.

American Society of Nephrology

  • Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
  • Don't administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.
  • Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.
  • Don't place peripherally inserted central catheters (PICC) in stage III?V CKD patients without consulting nephrology.
  • Don't initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.

American Society of Nuclear Cardiology

  • Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.
  • Don't perform cardiac imaging for patients who are at low risk.
  • Don't perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
  • Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.
  • Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

Big question is: how many members of these specialty societies will take these recommendations to heart and act on them?  Fair question.  In the meantime, I propose a standing ovation for these nine gutsy groups for doing the right thing by the American public.  What say you?

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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