Choosing Wisely: Physicians Take a Stand Against unecessary Tests and Treatments

The subject of unnecessary diagnostic testing is a contentious one that I’ve addressed here before (Overdiagnosis, Screening Tests). In human medicine, the government provides evidence-based guidelines for preventative healthcare interventions, including screening tests, through the U.S. Preventative Services Task Force (USPSTF). While being mostly ignored, this agency occasionally draws great controversy when challenging the classic American myths that More is Better and Statistics Don’t Matter. For example, after concluding that the evidence didn’t support routine screening mammography for as many women as had previously been told to have it done, the USPTF revised the screening guidelines. This generated a media conflagration on the scale of the Culture Wars, and led to a bunch of lawyers and politicians with remedial science knowledge passing legislation directing the government to ignore the evidence. Fortunately, other recommendations for less widespread screening for prostate cancer and cervical cancer have been greeted with less hysteria.

Still, the idea that unnecessary screening tests hurt more people than they help is a tough sell to those who don’t understand the complexities of reliability, validity, predictive value, and other factors involved in evaluating the risks and benefits of disease screening. Anecdotes about individuals who had a potentially serious disease detected by screening and believe that the subsequent treatment saved their lives are very compelling. They seem to get more coverage and have more impact than stories about people harmed by unnecessary treatment after detection of lesions that likely would never have caused them any problem. Nevertheless, unnecessary diagnostic tests not only cost a lot of money, reducing the resources available for providing necessary healthcare, but they also do harm many individual patients who are forced to go through unneeded secondary testing or treatment for diseases that either don’t exist or would never have made them ill.

A new organization of physicians has been formed to try and educate both clients and doctors about this problem and to make sound, evidence-based recommendations about diagnostic testing. Choosing Wisely has gotten a fair bit of media coverage lately for promoting lists of specific procedures that are often done unnecessarily, and for suggesting that these only be done when certain criteria are met. The lists also address some therapies which may be unnecessary, including the ever-popular excessive and inappropriate use of antibiotics.

These lists have generally avoided particularly controversial subjects, and so far haven’t been greeted with the panic that some of the USPSTF recommendations have. Hopefully, the effort will have some impact on physician behavior and consumer expectations. And once the organization and its approach is familiar and gains some credibility, perhaps they will be able to take on more controversial subjects, such as the lack of evidence to support annual physical examinations in adults without symptoms of illness (or even CAM therapies and tests not supported by evidence?).

 

 

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13 Responses to Choosing Wisely: Physicians Take a Stand Against unecessary Tests and Treatments

  1. Art says:

    I stopped sending out annual exam reminders about ten years ago. Phone shoppers for “annuals” are confused. Bonding the doctor to the client can be difficult.
    Art Malernee dvm
    Fla lic 1820

  2. skeptvet says:

    The evidence seems to suggest annual physical exams for asymptomatic humans are unecessary. I’m not aware of any evidence concerning annual exams for veterinary patients, but I can see some reasons why the situation might be different. In the absence of patient-reported symptoms, and with owners frequently not noticing even seemingly dramatic changes in their pets’ condition, a PE is often the only way a disease is detected. And depending on the lifestyle of the individual pet, locale, and other factors, diagnostic screenings for specific diseases may be appropriate for some pets on a regular basis, just as the evidence ndicates they are for some people. So I still recommend annual visits, though as always I try to be explicit that my basis for doing so is my own impression of what is useful, and there there is no controlled research evidence for or against the practice.

  3. Art says:

    Why not send out exam reminders every six months? When does the “usefulness” end?
    Art Malernee Dvm

  4. skeptvet says:

    Well, the whole point is we don’t know. Given the shorter relative lifespan of our patients, every 6 months might be more appropriate than every year. In any case, neither is any less arbitrary than never, which is also not supported by high-quality evidence. You seem to have a great deal of confidence in your recommendation, so I wonder what evidence you use to support that?

  5. Art says:

    I do not buy the life span exam argument. We would be doing physicals on rabbits And rats every month and the parrots would come in about every two years
    Art

  6. skeptvet says:

    So what reasoning or evidence do you rely on? Having an ironclad opinion based on nothing in particular isn’t very cogent.

  7. art malernee dvm says:

    So what reasoning or evidence do you rely on?>>>>> Human medicine evidence. I just checked the computer and see its been 16 years not ten since i stopped sending out annual reminders. Treating pets like people is not alway a good idea but if medical care has been shown not to help in human medicine i think we at least need to prove it helps pets before spending the clients money?
    art malernee dvm

  8. skeptvet says:

    Well, apart from the issue of extrapolation, which I agree is both problematic and often necessary, we have to remember that the conclusion in human medicine is only that physical examinations for adults with no clinical symptoms are probably unecessary. Routine screening tests or specific kinds of examinations are still recommended for patients with particular risk profiles. Screening for hypertension or other cardiovascular disease in smokers or men over a certain age, mammography/pap smears at an appropriate interval and based on the family history, BRC status, HPV status, etc…. There are lots of cases in which specific screening tests are clearly shown to improve outcome.

    S the question is partly what do we do when we lack the data to make suh graded assessments in our patients, or when we don’t have the time/energy/resources to do so? Should we schedule regular breast exams to intact female dogs over 5 years of age? Should we do regular checks for proteinuria or USG in cats over 8 years? In Wheaton’s? There is a balance between the costs of screening and the potential harm from unecessary procedures generated by unneeded screenings and the costs of failing to idnetify treatable diseases at an appropriate, ideally subclinical stage. I think in vet med we are ill-equipped to plan such screenings rationally due to a lack of appropriate, high-quality epidemiologic vidence. So while I think we have to acknowledge that the annual exam may be a waste of time and money for some patients, it may have significant benefits for others, and we don’t really know what the balance is.

  9. v.t. says:

    Art, if the client doesn’t listen to the vet and ignores the reminders, what do you suggest?

    And, I respectfully disagree that vets shouldn’t be sending out annual or bi-annual reminders for pets, at least we’re getting the client’s attention…after that, it’s their responsibility to act responsibly. If the pet is healthy, isn’t a 50.00 exam fee reasonable? (humans sure don’t pay a measly 50.00 for a regular physical exam, plus there is insurance, co-pays, etc to cover much of it – insurance is still debatable for pet owners) If the pet is not healthy and something is detected upon the exam, isn’t the 50.00 exam fee worth it? I’d bet the client wished they’d have paid attention to that annual reminder and saved themselves a great deal of heartache and costs of diagnostics and treatment (when catching early on could have minimized that).

  10. art malernee dvm says:

    Art, if the client doesn’t listen to the vet and ignores the reminders, what do you suggest?>>>

    I do not send out reminders any longer. When i did half of the clients acted responsibly and ignored them because I only based my reminders on how long it took the earth to revolve around the sun.

    >>>>>And, I respectfully disagree that vets shouldn’t be sending out annual or bi-annual reminders for pets, at least we’re getting the client’s attention…after that, it’s their responsibility to act responsibly.<<<<

    why not send out reminders every month for the real responsible clients. That should get their attention. How often do they need to come in to be responsible? By the way the management guys are promoting vets now split "annuals" up into multiple visits to decrease the sticker shock of the annual visit. So rather than come in for everything once a year you sent three reminders and get to see the client three times a year to avoid one big bill.
    art malernee dvm

  11. art malernee dvm says:

    in case the profession makes the decision to stop promoting “annuals” in the future i wanted to share what i do now. After taking a look at the animal and talking to the client I ask the client when they want to return. Often they tell me or ask me what I think. That gives me the chance to tell them the best time to take your pet to the vet is when you have a problem. i warn the client not to make the mistake of thinking just because the pet has been to the vet recently its ok to ignore new problems that pop up soon after the check up. If the pet has not been fully immunized yet or the client will run out of medication or i need to check to see if the problem is over we together make a decision about a follow up time. I try to get everything done at one time if i can. That does not always work. I had a client today that has no showed twice for scheduled deep dental cleaning with sedation that has a gum infection. I like to use the word concordance in my records. its the” involvement of patients in the decision making to improve patient compliance with medical advise”. It a hot word now in EBM and seems to help me understand that clients are experts too when it comes to their pet. So I put “no dental concordance” in the chart rather than dr advised owner declined dental. I try to think as a member of the team but its hard to think about cost effective veterinary care when i also need to take the owners money home and pay my own bills.
    art malernee dvm
    fla lic 1820

  12. v.t. says:

    Well, if the issue is only about reminders, and if it’s a cost-issue for you, then don’t send them. Otherwise, if it’s not prohibitive, then what’s the harm? You might catch several more clients who simply needed that reminder/nudge.

    That said, in my opinion, there are too many pet owners who only take their pets in when the pet actually does have a problem, waiting so long that the condition is difficult and lengthy to treat, or worse, impossible to treat, which negates the notion that pet owners are experts of their own pets’ health. Remember also, the major conditions that an equal number of pet owners don’t know how to recognize until it’s too late (for example, renal disease, heart disease, etc).

    I understand the monotony of drilling into clients’ heads the importance of catching disease early on with regular checkups, a reminder is but a simple way to do that. I’m not sure that tossing out simple methods like that is helping the client (or the pet).

    I’m not saying every young healthy adult pet actually needs an annual exam. Yet that annual exam fosters a relationship between vet and client where the client can ask questions, discuss potentials, get educated etc, where they otherwise might ignore a health issue until it is “convenient” for them to actually address.

  13. art malernee dvm says:

    good article this morning on lead time bias at the sciencebasedmedicine website which leads to doctors reporting better outcomes for testing and treatment then they really get if measured properly.
    see
    http://www.sciencebasedmedicine.org/index.php/cancer-care-in-the-u-s-versus-europe/

    I think it helps me to think of “annuals” as just a bunch of little test and treatments plus a consultation. Once we break the exam down to a bunch of little test we can make decisions what test to take to try and make a difference. For example some vets do rectals some do not unless symptoms occur. Randomized rectal outcomes could be measured in asymptomatic animals . This is one part of the exam owners cannot do at home. When blood pressure machines first came on the market for pets I took and recorded the systolic and diastolic pressure of every pet that came in to the office for annuals for about two years. Blood pressure could be randomized and measured. Even the consultation of asymptomatic animals could be randomized. Half in the office Half by email. Since sudies show about half of our clients do not think they need to bring the animal in to the office if they have no problems a email consultation may be more effective then sending out a reminder for something that has not been proven to help since you might get better compliance by email. The annual blood pressure checks did not help my practice as far as i could tell. I have noticed that texting clients seems to bond them to me and we reach concordance on test and treatments more frequently. the big problem is getting paid for your time rather than just selling test and treatments. The new trend around my office is to give away the first office visit for free. So many phone callers do not want to even pay for their first visit unless they buy something. I think that system leads to problems if you cannot make a living telling people what they do not need. It does seem to attract business but then the client comes to see me for a second opinion and does not want to pay for the first visit. Its like the old days when the annual exam consultation was free with the annual vaccines that the immunized pet does not need.
    art malernee dvm
    art malernee dvm
    fla lic 1820

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