Stop The Over Testing

I am torn on this.  As a family doctor who also thinks himself as a steward of the healthcare system, I love the idea of a “campaign to fight unneeded tests“.   The first 45 recommendations came out last April.    There are now a total of 135 with the ones below recently added.   My question is simple.  Will this hold up in a court of law or with the state boards of medicine if a patient decide to sue or report the doctor? Don’t be so quick to say yes.

18 interventions primary care doctors should question or avoid

The medical specialty societies participating in the Choosing Wisely campaign have identified 90 more examples of potentially inappropriate care. Among them are items especially relevant to primary care physicians and their patients, which say:

  1. Don’t schedule elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks’ gestational age.
  2. Avoid elective, nonmedically indicated inductions of labor between 39 weeks and 41 weeks unless the cervix is deemed favorable.
  3. Don’t screen for carotid artery stenosis in asymptomatic adult patients.
  4. Don’t screen women older than 65 for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
  5. Don’t screen women younger than 30 for cervical cancer with human papillomavirus testing, alone or in combination with cytology.
  6. Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
  7. Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children younger than 4.
  8. CT scans are not necessary in the immediate evaluation of minor head injuries; clinical observation and Pediatric Emergency Care Applied Research Network criteria should be used to determine whether imaging is indicated.
  9. Neuroimaging is not necessary in a child with simple febrile seizure.
  10. Don’t perform routine annual Pap tests in women 30 to 65.
  11. Don’t treat patients who have mild dysplasia of less than two years in duration.
  12. Don’t screen for ovarian cancer in asymptomatic women at average risk.
  13. CT scans are not necessary in the routine evaluation of abdominal pain.
  14. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
  15. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  16. Avoid using medications to achieve hemoglobin A1c of less than 7.5% in most adults 65 and older; moderate control is generally better.
  17. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
  18. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Sources: Choosing Wisely lists of five things physicians and patients should question by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists and American Geriatrics Society

 

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  14 comments for “Stop The Over Testing

  1. Dr. Bill Ameen
    March 17, 2013 at 3:39 pm

    I would add that if we really want to cut costs, eliminate unnecessary physical exams. Now companies are sending their employees over for “wellness” (God, how I hate that word) exams to find insurance savings. I would also go back decades to ceasing sports preparticipation exams (in all the hundreds I’ve done through the years I’ve found one IgA nephropathy and had one kid with a anomalous coronary circulation who collapsed but survived months after my normal exam). Oh, and no more DOT exams. Truck accidents are nearly always caused by human error or weather. Did you know that by 5/2014 only “providers” who have had a >$400 course with a $79 exam will be allowed through certification to do DOT exams? I would say that means 95% of those of us doing them mindlessly for years will stop doing them (including chiropractors…yes, there’s a box for D.C.’s to sign DOT physicals also!). If we want to get serious about saving money in healthcare, let’s look at everything. In my mind, we don’t need thousands more doctors, we need doctors who can work harder and be better reimbursed without being burdened with foolishness. That implies the patients will finally need to have some responsibility: don’t go to doctors with “colds,” poison ivy, minor bumps and bruises, and especially not “wellness checkups”!!

    • Doug Farrago
      March 18, 2013 at 5:29 am

      well said

  2. Carmen Nan
    March 13, 2013 at 9:57 pm

    The c-sections excess should be blamed solely on John Edwards who impersonated a baby in distress in court in order to elicit sympathy and a large award from a jury for a cerebral palsy case. After that the rate of c-sections across the country skyroketed even though there is no evidence that early c-sections prevents CP and as such the rate of C- sections increase should have correlated with a …lower rate of CP which alas did not happen.
    But it is also true to all of you docs out there that if we do not cut things like these ourselves we are going to have bureaucrats in Washington cut with a blunt instrument so there you have it pick your poison : die by lawyers or die by government.I would much rather have my doc explain to me why a test may not be needed or of very little benefit rather than a guy in Washington with no medical knowledge whatsoever cut something that may be necessary… That or our dollar will be worth nothing or our kids will work for pennies…

    • Pat
      March 14, 2013 at 9:45 am

      Either way we die, and so it becomes a question of prolonging one’s economic survival. But what of the patient? They chose Washington, and lawyers to be their advocates over their physicians, substituting institutionalized compassion for their own judgement. Once we devalued our reason, it follows that our currency would follow suit.

  3. mamadoc
    March 13, 2013 at 8:32 pm

    Ditto, Dr Conrad. The jury, which is not only NOT of your peers but generally contains the unemployed, underemployed, discontented and not very bright doesn’t know or care what the standard of care is. It IS about the outcome, even if it is an act of God.

  4. David Bertoncini
    March 13, 2013 at 1:07 pm

    Someone let the government Medicare idiots at PQRI and NCQA know that A1c around 7.5 is optimal. They’d rather pay us bonuses and give us special recognitions when we create hypoglycemia and brain injury in old folks, based on bad science. (Doug, do you have the power to fix this?)

  5. Mark OBrien
    March 13, 2013 at 1:03 pm

    It will take 2 to 3 years to work the cases through the legal system and there will be sacrificial lambs along the way before a final end result. And it’s not about facts anyway. $$$$

  6. Kathy Wire
    March 13, 2013 at 11:37 am

    I seem to be the devil’s advocate a lot these days…;-) I work in the defense of claims. If the evidence shows that a test or procedure can cause more harm than good, and the doctor does not recommend it, we can defend that. Proviso: all factual concerns relevant to the decision should be in the chart (age, history, etc.) and (while I know this makes many doctors’ hair stand on end) it is usually a good idea to talk to the patient, esp if they are used to the “old” way.

    The harm does happen: I have a kid with ulcerative colitis. I would bet a house payment that it resulted from the disruption of her intestinal flora when she took nuclear strength antibiotics for persistent sinus infections during her pre-school years. I am guessing that now they would have simply watched and waited. Fortunately it has responded well and all is [pretty] good.

    Keep a few of those stories in your back pocket for the “talk.”

    And there is absolutely no excuse for the early inductions and c-sections or for treating non-symptomatic positive urine cultures, esp in the elderly. I’ve had to deal with the adverse results of those in my professional life and it breaks my heart.

    • Doug Farrago
      March 13, 2013 at 12:41 pm

      I will!

  7. DrHockey
    March 13, 2013 at 10:56 am

    “My client would have GLADLY paid for that test out of her own pocket if her doctor had only requested it.”

  8. Stephen T. Smith, MD
    March 13, 2013 at 10:51 am

    While there may be anecdotes to the contrary, as a general rule, a physician is expected to behave as any reasonable physcian from that community would in that circumstance. Often, it is that physicians do not adhere to the guidelines used by their own institutions/colleges. Excessive technology does not protect you. The counter to this is the anecdote: “I knew a doctor who….(fill in the blank).” Most of the time, you are held to a standard of your training and community…not to be clairvoyant and forsee all potential (and sometimes potentially unknowable) events.

    • Pat Conrad
      March 13, 2013 at 2:14 pm

      Sure, that’s how I and several physicians I personally know, have been sued and settled against, even when expert depositions confirmed that the standard of care for that community and level of training was met.

      The clinical outcome often determines whether suit is brought, irrespective of care; whether or not the checklist tests/interventions were ordered determines whether the doc is thought to be at fault. At least, that’s how I see it from now on.

  9. R D Braun
    March 13, 2013 at 9:35 am

    This would cut the cost of medical care in half. But the lawyers won’t let us do it.

    • Dougz Given
      March 13, 2013 at 3:42 pm

      I have seen some women under 30 have some gnarly cervical cancer.

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