Wise medicine

Having an executive checkup? You presume an exercise ECG (electrocardiogram) should be part of it.

Now comes advice from the American College of Physicians saying this test should not be used on people who have no symptoms of, or are at low risk for, coronary heart disease.

Billions of dollars are wasted each year in the United States on unnecessary medical tests and procedures such as this exercise ECG.  Now there’s hope that this tremendous waste can be reduced, both in the United States and other countries like the Philippines, which tend to follow the US health care model.

The hope comes with a “Choosing Wisely” initiative involving nine medical specialty groups urging physicians and patients to ask more questions before agreeing to 45 medical tests and procedures. The initiative was coordinated by the American Board of Internal Medicine Foundation, which is also working with another eight medical associations that might release more lists of unnecessary tests and procedures. After extensive consultations and a review of the studies made around particular procedures, each of the first batch of specialty groups finally agreed to choose five procedures that they felt were unnecessary, costly or even risky. The specialty groups looked into cost-benefit studies as well, involving not just financial costs but also patients’ anxieties.

There are many reasons for the overprescribed tests, one being that patients themselves sometimes demand the tests, often because they’re dazzled by the technology: ultrasound (first 3D, now 4D), computed tomography (CT) scans, magnetic resonance imaging (MRI). In an interview on the American Public Broadcasting System, one expert, Dr. Eric Topol, observed how cardiologists order nuclear stress tests as a “routine, knee-jerk thing.  And that exposes each individual to a lot of radiation, equivalent to thousands of chest X-rays.”

American doctors argue that they order tests because of a fear of a misdiagnosis, and malpractice suits. Then there’s the blunt reality of doctors making more money—from direct patient payments or from health insurance companies and health maintenance organization—when the tests are ordered.

The specialty groups are working with Consumers Reports to provide the public more information on their program. To start off the program, each specialty group has produced a pamphlet titled “Five Things Physicians and Patients Should Question.”  All the materials are available on the Internet (choosingwisely. org).

Headaches, cysts

Many of the procedures discussed in the pamphlets are quite technical but I thought of sharing a few of the simpler, and very common, procedures that have special relevance in the Philippines:

From the American College of Radiology: “Don’t do imaging for uncomplicated headaches.” I found this almost amusing and had to remind myself that many people (including physicians themselves) do worry about persistent headaches, imagining some kind of brain tumor.

The ACR also says that after a good quality ultrasound, “follow-up imaging tests are not recommended for clinically inconsequential adnexal cysts.”  This I thought was especially important for the Philippines because the word “cyst,” like “bukol,” causes so much undue stress in women. Yet, the ACR notes that “simple cysts and hemorrhagic cysts in women of reproductive age are almost physiologic” (meaning they’re normal) while “small simple cysts in postmenopausal women are common, and clinically inconsequential.”

From the American Society of Nephrology: “Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.” The ASN notes that available research suggests that chronic dialysis might not make that much of a difference in survival rates for older people who have other diseases besides those of the kidney.

From the American Academy of Allergy, Asthma and Immunology is a recommendation to actually use a test:  “Don’t diagnose or manage asthma without spirometry.” These are measurements of how air flows through a patient’s lungs. I’ve heard, too often, of patients, usually children, in the Philippines being told they have asthma simply because they wheeze, and then are put on powerful drugs like steroids.

Also from the AAAAI: “Don’t perform unproven diagnostic tests, such as immunoglobulin G testing (IgG) or an indiscriminate battery of immunoglobulin E (igE) tests in the evaluation of allergy.” It notes that the more appropriate procedure is to use specific tests, based on the patient’s clinical history (e.g., the time when the allergies occur).

Two of the specialty groups warn against ordering imaging tests for low back pain. The American College of Physician notes that such tests for non-specific pain do not lead to better outcomes; the American Academy of Family Physicians suggests waiting until after six weeks before ordering the tests. Low back pain is a very common complaint and physicians tend to order tests right away even when these are not needed.

The family physicians’ group also advises against performing Pap smears on women younger than 21 since observed abnormalities often will disappear spontaneously. Pap smears are also deemed unnecessary in women who have had a hysterectomy (removal of the uterus) for non-cancer disease.

Medicines, too

The Choosing Wisely initiative will also tackle some unnecessary or overused pharmaceuticals. In this initial set of recommendations there are already a few warnings about some drug treatments—for example, the American Gastroenterological Association says that patients with GERD (gastroesophageal reflux disease) should be treated “with the lowest effective dose needed to achieve therapeutic goals.”  GERD is becoming more frequently diagnosed in the Philippines and there’s a tendency for physicians to start with a high dose of drugs, but the AGA notes that if this is done, it is harder to stop treatment later on, or to reduce the dose, because what happens is the patient actually gets more serious symptoms.

The American Academy of Family Physicians, on the other hand, advises against routine prescriptions of antibiotics for acute sinusitis, “unless the symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.”

Choosing Wisely is relevant for the Philippines, where expensive tests pose an even greater burden on patients. Unfortunately, like Americans, many Filipinos still think a physician is good if he or she prescribes the latest drugs or uses the latest technological gadgets. There’s much less appreciation of physicians who have developed their expertise through accumulated experiences, literally able to sniff out certain diseases, with that intuitive sense that anticipates the results of the fanciest clinical tests.

If Choosing Wisely takes off, we may better appreciate physicians who are wise and prudent in the use of technologies. But we shouldn’t forget choosing wisely is something both physicians and patients must learn to do together.