LIFE IS A SERIES OF CHOICES

On a number of occasions, my wife has reminded me that “life is a series of choices’ (especially after I’ve made, what she considered, the “wrong choice”).

Similarly, the practice of medicine can be viewed as a series of choices.

For example:

• Should I prescribe an antibiotic for this patient’s acute bronchitis?
• Should I order an MRI for this patient’s low back pain?
• Should I continue treating this condition myself or refer to a specialist?
• Should I continue to observe and monitor or is it time to operate?
• Should I discharge my patient today or keep him/her in the hospital another day?

As it turns out, many of the treatment choices we make may be considered of no or low value to the patient. Several studies have shown that, on average, about 30% of such treatment decisions fall into this no/low value category. A survey commissioned by the American Board of Internal Medicine (ABIM) in 2014 included the following findings:

Nearly ¾ of U.S. physicians say that the frequency with which doctors order unnecessary medical tests and procedures is a serious problem for America’s health care system

72% of physicians say that the average medical doctor prescribes an unnecessary

test or procedure at least once a week.

53% of physicians say that even if they know a medical test is unnecessary, they order it if a patient insists.

To help address these concerns, the ABIM launched the “Choosing Wisely®” campaign in 2012 which is designed to promote conversations between clinicians and patients by helping patients choose care that is:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

Medical specialty societies were called upon to identify tests or procedures commonly used in their fields whose necessity should be questioned and discussed with patients. To date, over 70 medical specialty societies have published more than 500 recommendations of overused tests and treatments. These are accessible through the Choosing Wisely website (www.choosingwisely.org) where you can also download the Choosing Widely app to your iPhone/iPad or Android device. Some examples include:

• (from Anesthesiology) Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically, CBC, BMP or CMP, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal
• (from Pulmonology) For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia.
• (from Dermatology) Don’t prescribe antifungal therapy for suspected nail fungus without confirmation of a fungal infection. Approximately half of all patients with suspected nail fungus do not have a fungal infection.
• (from Cardiology) 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.
• (from Gastroenterology) For a patient with functional abdominal pain syndrome (as per ROME IV criteria) CT scans should not be repeated unless there is a major change in clinical findings or symptoms.

I invite you to visit the Choosing Wisely website and review the recommendations pertinent to your specialty. You may or may not agree with all of them though keep in mind that these are recommendations promoted by the pertinent specialty society. And, of course, guidelines and recommendations are just that – “guidelines” to help “guide” your clinical decisions, not supplant your clinical judgement.

Avoiding unnecessary medical tests, treatments and procedures is good medicine and, as such, should be part of the Alliance’s mission to enhance the health of our population.