Choosing wisely seems like good advice, whether the object is friends, a college, or a spouse. But now, a broad coalition of medical societies and consumer watchdog groups, such as the AARP and Consumer Reports, are issuing the same counsel to the general public about medical care. Their message: It is good to have choices, but be sure to Choose Wisely. ®
The origin of this public health campaign is a recognition that the demand among the public for certain medical tests and therapies, rather than lead to better health, often is the first step on the twisty road to medical misadventure. Some jargon-enthralled pundits call these tests ‘low value’ health services pointing to the waste of billions of dollars on unnecessary tests. But arguing about ‘value,’ a term fraught with calculations about cost effectiveness, misses the point. A simpler term makes the point better: harm.
Depending upon the situation, some tests, procedures and medications are more likely to harm a person than help them. Three examples will be illustrative.
Infections of the sinus afflict millions of people each year, but the causes are overwhelmingly due to viruses and are thus unaffected by anti-bacterial antibiotics. Yet millions of prescriptions get written for antibiotics for sinusitis annually, often in response to patient request and expectation. But antibiotics have side effects both for the individual who takes them, and for society at large, as overuse drives community-wide antibiotic resistance and accelerates the proliferation of so-called “super bugs”-bacteria that are resistant to entire classes of antibiotics. Overuse of antibiotics also contribute to a potentially lethal infection of the gut, known as C. Diff. The American Academy of Allergy, Asthma and Immunology recommends restricting antibiotics to certain clinical types of sinusitis, thus sparing most of us the risks.
Similarly, the American Academy of Family Physicians recommends not performing routine screening tests such as EKG, or stress tests for people who have no symptoms and are at low risk for heart disease. These tests among those without symptoms or risk factors have a high rate of false positives that will lead to either more testing or over treatment.
Finally, the American College of Radiology advises patients not to ask for CT scans or MRIs of the brain because of “uncomplicated” headaches-those without accompanying neurologic signs and symptoms. They are almost never helpful in discovering the cause or in rendering treatment. Moreover, they can also identify findings that turn out to be false positives, but only after a lot of anxiety and follow up scans. And then there is the exposure to unnecessary radiation. CT scans of the head deliver least 25 times as much radiation to the head as a chest x-ray delivers to the chest.
Experienced physicians know that unnecessary medical testing or therapies can generate its own momentum and expose patients to harm. Over testing and over treating can turn a healthy person into a “patient,” a lamentable transformation. The Choosing Wisely® guidelines help both physicians and the public to avoid that trap. They are designed to help patients and doctors have a dialogue. These guidelines can be viewed at the web site http://www.choosingwisely.org/doctor-patient-lists/
So the next time you see or read a story about runaway medical costs and poor outcomes, recall the wisdom of Cassius from Shakespeare’s Julius Caesar, “The fault, dear Brutus, is not in our stars but in ourselves…”.
Got symptoms? Have a conversation, not a test.
Barry Meisenberg, MD, is the Chair for Quality and Patient Safety and the Director of the Center for Healthcare Improvement at Anne Arundel Medical Center.