Medicine
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality primary care. The March 1st issue of American Family Physician includes two articles that reflect this philosophy as embodied in the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Four of the American Geriatrics Society's "Five Things Patients and Physicians Should Question" refer to medications that can be harmful to older patients in certain settings: antipsychotics, hypoglycemics, benzodiazepines, and antibiotics. Dr. Richard Pretorius and colleagues echo this advice and provide additional guidance and systematic approaches to reducing the risk of adverse drug events in older adults.
Sudden hearing loss is a distressing symptom that may prompt a physician to order a CT scan to look for a brain tumor or other cranial mass lesion. However, the American Academy of Otolaryngology - Head and Neck Surgery Foundation advises against ordering this diagnostic test in patients without focal neurologic findings, since the CT scan provides no useful information and exposes the patient to radiation and an expensive medical bill. More information on the evaluation and management of sudden hearing loss is available in AFP's Practice Guidelines summary of the AAO-HNSF's recent clinical guideline.
One reason that clinicians often give for ordering diagnostic tests in patients with a low pretest probability of serious disease is to "reassure the patient." This rationale is used to justify performing endoscopy in patients with dyspepsia but no alarm symptoms; x-rays or magnetic resonance imaging in patients with uncomplicated low back pain; or electrocardiography in patients with chest pain and a low likelihood of cardiac disease. It turns out, though, that negative tests aren't reassuring at all. A recent systematic review and meta-analysis of 14 randomized trials in JAMA Internal Medicine found that diagnostic tests did not reduce patients' illness worry, nonspecific anxiety, or symptom persistence. The only effect of the tests was a small reduction in subsequent primary care visits. Given the adverse effects of diagnostic testing in general, including false positives and overdiagnosis, this "benefit" does not warrant making unwise choices about non-indicated medical tests.
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The above post was first published on the AFP Community Blog.
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Medicine
Extra diagnostic tests don't reassure: another reason to Choose Wisely
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality primary care. The March 1st issue of American Family Physician includes two articles that reflect this philosophy as embodied in the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Four of the American Geriatrics Society's "Five Things Patients and Physicians Should Question" refer to medications that can be harmful to older patients in certain settings: antipsychotics, hypoglycemics, benzodiazepines, and antibiotics. Dr. Richard Pretorius and colleagues echo this advice and provide additional guidance and systematic approaches to reducing the risk of adverse drug events in older adults.
Sudden hearing loss is a distressing symptom that may prompt a physician to order a CT scan to look for a brain tumor or other cranial mass lesion. However, the American Academy of Otolaryngology - Head and Neck Surgery Foundation advises against ordering this diagnostic test in patients without focal neurologic findings, since the CT scan provides no useful information and exposes the patient to radiation and an expensive medical bill. More information on the evaluation and management of sudden hearing loss is available in AFP's Practice Guidelines summary of the AAO-HNSF's recent clinical guideline.
One reason that clinicians often give for ordering diagnostic tests in patients with a low pretest probability of serious disease is to "reassure the patient." This rationale is used to justify performing endoscopy in patients with dyspepsia but no alarm symptoms; x-rays or magnetic resonance imaging in patients with uncomplicated low back pain; or electrocardiography in patients with chest pain and a low likelihood of cardiac disease. It turns out, though, that negative tests aren't reassuring at all. A recent systematic review and meta-analysis of 14 randomized trials in JAMA Internal Medicine found that diagnostic tests did not reduce patients' illness worry, nonspecific anxiety, or symptom persistence. The only effect of the tests was a small reduction in subsequent primary care visits. Given the adverse effects of diagnostic testing in general, including false positives and overdiagnosis, this "benefit" does not warrant making unwise choices about non-indicated medical tests.
**
The above post was first published on the AFP Community Blog.
- Curbing Overuse Is An Important Part Of Quality Improvement
In the late 1990s, the urban public hospital where I trained as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present...
- The Consensus In Preoperative Testing: Less Is More
Family physicians are often asked for preoperative consultations prior to elective surgical procedures. Traditionally, the process of "clearing" patients for surgery has included performing an electrocardiogram, chest x-ray, and numerous laboratory tests....
- Choosing Wisely's Curious Omissions
Last month, the American Board of Internal Medicine Foundation's Choosing Wisely Initiative announced the release of a second round of lists of 5 things that physicians and patients should question, based on evidence that certain tests or procedures...
- Too Much Medical Care: Do We Know It When We See It?
The year after I moved to Washington, DC, I visited an ophthalmologist for a routine vision examination and prescription for new glasses. Since undergoing two surgical procedures to correct a "lazy eye" as a child, I hadn't had any issues with my...
- The Presidential Physical
Based on standards set by the U.S. Preventive Services Task Force (USPSTF), the widely respected independent committee of primary care health professionals that for more than 25 years has rigorously reviewed the evidence for benefits of clinical preventive...