The American Academy of Family Physicians (AAFP) has added
five new recommendations to its Choosing
Wisely campaign. I have discussed “Choosing Wisely” before (‘“Eggs
Benedict” and “Choosing Wisely”: Often the best thing to do is nothing’,
April 14, 2012), but will briefly review it. First introduced by the American Board
of Internal Medicine Foundation (ABIM-F), the program calls for each specialty
society to list at least five things that are done by members of that specialty
but either should not be done at all
or should only be done in far more restricted circumstances that they currently
are.
The five new recommendations by the AAFP bring their total
to 20; this is good, because many other specialty societies have never expanded
upon their original five. And for some of those groups, even those original
five were kind of tentative, almost like “well, this test or procedure is not
good, so you probably shouldn’t use it too much”. One reason Family Medicine has more is because
the field is so broad and its practitioners care for problems in all areas, but
I fear that another reason is the reticence of some specialty societies to make
negative recommendations about things that their members make a lot of money from
doing, even if they are not medically indicated. As I noted in ‘Medical
interventions we shouldn’t be getting: issues of cost, health, and equity’
(December 12, 2015) regarding imaging for uncomplicated back pain:
…some
of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were
imaging studies not recommended by the American
Academy of Family Physicians and American
College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are
not recommended against by the American
Academy of Orthopaedic Surgeons in their “Choosing Wisely
recommendations. Of course, orthopedists stand to benefit from doing surgery on
these patients.
The radiologists, who perform the MRIs and CTs, also did not
recommend against this procedure.
The radiologist societies also recommend screening for lung
cancer with low-dose CT scans in smokers and former smokers, and in fact, to
date, none of the specialty societies are recommending against it. There is some
evidence that this (not inexpensive) test may be able to detect lung cancer
early in many people, sometimes while it still can be effectively treated, but
even this is not certain. Rita L. Redberg, MD, in an editorial in JAMA Network “Failing
Grade for Shared Decision Making for Lung Cancer Screening”, notes that while
(payment by Medicare for) the test was approved on the basis of one positive
study, three subsequent studies have not shown the benefit. In addition, it is
not without risk of harm. The harms come not only from radiation exposure, but
from complications of the biopsies needed to follow up on positive tests. And,
also noted by Redberg, 98% of positive
tests are “false positives”, where the patient does not have cancer. Some
of this high percentage of false positives comes from testing the wrong people
(“screening creep”, where a test that has been shown to be of benefit in a
limited population is incorrectly assumed to also be of benefit to a wider
group). the US Preventive Services Task Force (USPSTF) recommends that the screening
only be done on the patients for whom it is indicated (!!), and only after the doctors
engage in “shared decision making” (SDM) with their patients by helping them
understand both the potential risks as well as benefits to the test, and what
their individual probability of each is.
Apparently, doctors do not do this, as demonstrated by the
research article that Redberg’s editorial accompanies, “Evaluating
Shared Decision Making for Lung Cancer Screening” by Brenner, Malo,
Margolis, et al. Taping and analyzing recordings of doctors recommending this
test to their patients, they found no
evidence of the physicians presenting the important information and engaging in
SDM. It was a small sample (this is difficult and time-consuming work), but as
Redberg points out there is no reason to imagine that overall practice is
significantly different. While this study specifically looks at low-dose CT
screening for lung cancer, and finds that SDM doesn’t happen often, this is a
concern for many other tests and interventions that are often done when they
are not indicated, and rarely have the risk/benefit presented to people so that
they can participate in SDM.
One example of such a test is the use of screening pelvic
examinations (the part where the provider puts her hands in and feels around,
not the Pap smear part) in non-pregnant women. One of the AAFP’s new “Choosing
Wisely” recommendations (#16) appropriately comes out against it: “Don’t perform pelvic exams on asymptomatic
nonpregnant women, unless necessary for guideline-appropriate screening for
cervical cancer”. This is because
the most basic characteristic of a screening test (essentially, any test –
whether a physical exam or lab or x-ray – done in asymptomatic people) is that
there has to be a disease that the test can, with some reasonable rate of
accuracy, screen for. There is no condition that can be screened for by a
pelvic examination (including ovarian cancer, which has been cited, and is
always too advanced to successfully treat by the time it can be felt). I have
been teaching students and residents to not do “screening” pelvic examinations
in asymptomatic non-pregnant women for decades.
For similar reasons, previous AAFP “Choosing Wisely” recommendations,
had already recommended (#5) against doing Pap smears in women in whom it is
not indicated (those who are under 21 or have had removal of their cervix for
non-cancer disease), and in women over 65 who have had negative prior Paps and
are not at high risk for cervical cancer (#9), and not requiring either Paps or
pelvic exams for prescribing oral contraception (#15). In addition to not doing
a screening test when there is no disease to screen for (pelvic exams), they
should also not be done when the risk is very low and lead to excessive false
positive tests. This seems like a lot of “don’t dos” in the same general area
of women’s screening, but it is warranted not only because family physicians do
a lot of such screening, but, more embarrassingly, because many OB/Gyn
specialists both continue to do them and to teach students and residents to do
so. Indeed, not doing screening pelvic examinations is distinctly not one of the 10 “Choosing Wisely”
recommendations by the American College of Obstetricians and Gynecologists
(ACOG).
Yes, OB/Gyns do make some of their living doing such
procedures (as do family doctors), but frankly it is a small percent compared
to doing surgical procedures. Sometimes tests and procedures continue to be
done even when they are not indicated (or potentially harmful) because of
tradition. Or because of publicity campaigns run by disease-specific advocacy
groups, especially for various types of cancer, that sow fear rather than
truth.
But when such tests and procedures continue to be done, even
in part, because those who perform them, the doctors and hospitals and
laboratories and device makers, make money doing them rather than for medical
benefit, it is reprehensible. And, even more, it saps funds from other
important health-related care, particularly for those people who have the least
money and are least likely to be insured. We do not have a unitary national
health system in which money not needed in one area can be easily transferred to
spending on necessary care for other people or conditions, but we need to get
there.
It is unacceptable for people to get tests and procedures
that are dangerous and of no benefit regardless of funding. It is similarly wrong
for even relatively benign tests and procedures that are not medically
indicated to be done because those performing them make money. But it is worst
that many people do not get even basic, indicated, beneficial care while money
is being wasted, or worse, on these other procedures.
The terribly flawed attitude of treating healthcare as a
business was illustrated by a comment from Charles Bouchard, senior director of
theology and ethics at The Catholic Health Association, in a NY
Times article that found fewer
than 3% (all in Washington State, which legally requires it) of Catholic
hospital websites “contained an easily found list of services not offered for
religious reasons.” He said '“I think that any business is not going to lead
off with what they don’t do. They are always going to talk about what they do
do. And that goes for contractors and car salesmen. They are not going to start
off by saying, ‘We don’t sell this model,’ or ‘We don’t do this kind of work.’”
That’s the problem. Selling things people do not need to
them if they have money (and not offering things there is no profit in so doing)
is a common way to run a business. It is no way to run healthcare.
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