Thursday, April 5, 2012

Specific Don’t Do Lists for Doctors
If you’re going to change something, be specific.
To define is to exclude and negate.

Jose Ortega Y Gasset (1883-1955), Meditations on Quixote

Never, never, never, never, never!

Shakespeare (1564-1616), King Lear , V

April 5, 2012 – Doctor Organizations are responding to the off-quoted generalization that one-third of medical tests and procedures are unnecessary.  

Nine physician organizations have listed 45 things that their members should never do.   As you peruse this list of 45 don’ts, note that many of them focus on imaging procedures and other diagnostic tests on asymptomatic patients. 

Physicians are a compulsive lot.  Otherwise they would not be physicians. Many order tests and procedures as a defensive measure should  they ever  be asked by an attorney, “Why didn’t you order such and such a test, doctor?”   Maybe it would be a good idea to send this list to the American Trial Lawyers association.  Many physicians may now feel that they will be damned if they do and damned if they don't.

For brevity, I have used the following abbreviations -  Dx for diagnosis or diagnostic; Rx for treat or treatment; Sx for symptoms. 

American Academy of Allergy, Asthma, and Immunology

1.       Don’t perform unproven  Dx tests, such immunoglobulin G or G to evaluate allergies.

2.       Don’t order sinus CTs, or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

3.      Don’t routinely do Dx tests for patient with chronic urticaria.

4.      Don’t recommend  replacement  immunoglobulin Rs for recurrent infections unless impaired  antibody response to vaccines are demonstrated .

5.      Don’t dx or manage asthma without spirometry.

American Academy of Family Physicians
6.      Don’t do imaging for low back pain within 1st six weeks, unless red flags are present.

7.      Don’t routinely prescribe antibiotics for mild or chronic sinusitis unless Sx last for 7 or more days or SX warrant clinical intervention.

8.      Don’t use dual energy x-ray absorption (DEXA) screening for osteoporosis in women under 65 or men under 70 with no risk of fractures.

9.      Don’t offer annual EKGs or other screening for low risk patients without Sx.

10.  Don’t’ perform PAP smears on women under 21 or who have had a hysterectomy for non-cancer disease.

American College of Cardiology

11.  Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac Sx unless high-risk markers are present.

12.  Don’t perform annual street cardiac imaging or advanced non-invalid imaging as part of routine follow-up in aSx patients.

13.  Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in a patient scheduled to undergo low-risk non-cardiac surgery.

14.  Don’t perform echocardiography as routine  follow-up for mild aSx native valve disease in adult patients with no change in signs or Sx.

15.  Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated non-hemodynamic stable ST-segment elevated myocardial infarction (STEMI).

American College of Physicians

16.    Don’t  obtain screening exercise EKG testing in individuals who are aSX or at low risk for heart disease.

17.    Don’t obtain imaging studies in patient with nonspecific low back pain.

18.  In evaluation  of simple syncope and normal neurologic exam, don’t obtain brain imaging studies (CT or MRI).

19.  In patients with low pretest probability of thromboembolism, obtain a high-sensitive D-dimer measurement as the initial Dx test; don’t obtain imaging studies as the initial Dx test.

20.  Don’t obtain preoperative  chest lin absence of clinical suspicion of intrathoracic pathology.

American College of Radiology                                   

21.   Don’t do imaging studies for uncomplicated headache.

22.  Don’t image for suspected pulmonary embolism without moderate or high pre-test probability.

23.  Avoid admission or pre-operative chest X-ray for ambulatory patients with unremarkable histories or physical exams.

24.  Don’t do CT for evaluation of suspected appendicitis for children until after ultrasound has been considered as an option.

25.  Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

American Gastroenterological Association

26.   For drug RX of patients with GI reflux disease (GERD), long term acid suppression should be titrated to lowest effective dose to achieved Rx goals.
27.  Do not repeat colorectal cancer screening for 10 years after a high quality colonoscopy is negative for an average risk individual.

28.  Don’t repeat colonoscopy for 5 years in patients with 1 or 2 small (less than 2 cm) adenomatous polyps, without high grade dysplasia, completely removed via a high-quality colonoscopy.

29.  For a patient with Barrett’s esophagus, who has undergone a 2nd endoscopy a follow-up surveillance exam should not be performed in  less than 3 years.

30.  For a patient with functional abdominal pain syndrome, CT scans should not be repeated unless there is a marked change in clinical findings or Sx.

American College of Clinical Oncology

31.  Don’t use cancer-directed Rx for solid tumor patients with these follow-up characteristics: low performance status (3 or 4);  no benefit from prior-evidence-based interventions, not eligible for clinical trials, and no strong evidence of further clinical value.

32.   Don’t perform PET, CT, or radionuclide bone scans in stages of early prostate cancer at low risk for metastases.

33.  Don’t perform PET, CT, or radionuclide bone scans in early breast cancer at low risk for metastases.

34.  Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, or radionuclide scans) for aSX individuals who have been Rxed for breast cancer with curative intent.

35.  Don’t use WBC stimulation factor for primary prevention and febrile neutropenia for patients with less than 20%risk for this complaint.

American College of Nephology

36.  Don’t perform routine cancer screening for dialysis patients with limited life expectancy  and without signs or Sx.

37.  Don’t administer erythropoiesis stimulating agents (ESAs) to chronic disease patients  with hemoglobin levels of 10 g/dl without signs or Sx.

38.  Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension, heart failure. CKD of all causes, including diabetes.

39.  Don’t place peripherally inserted central catheters (PICC) in stage III-IV CKD patients without consulting nephrology.

40.  Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.

American Society of Nuclear Cardiology

41.    Don’t perform cardiac stress imaging or coronary angiography in patients without cardiac Sx unless high risk markers are present.

42.  Don’t perform cardiac imaging for patients at low risk.

43.  Don’t perform radionuclide  imaging as part of routine follow-up in aSX patients.

44.  Don’t perform cardiac imaging as a preoperative assessment in patients scheduled to undergo low or intermediate risk -surgery.

45.  Use methods to reduce radiation exposure in cardiac imaging, including not performing such tests when limited benefits are likely.


As a general proposition, doctor don't do lists are a good idea.  They may cut costs and end most unnecessary tests.   But in medicine there are no absolutes.   On occasion,  one will do and must do what one said one should ideally never do.   Even Supreme Court Justices know this.  As Supreme Court Justice Oliver Wendell Holmes, Jr., said in a letter to his friend Pollock in 1920, "I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn."

Tweet:  Nine medical societies have issued a list of 45 things not to do when evaluating or treating patients.

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