Fifteen things good doctors should avoid – Choosing Wisely II

Less is moreThis is important reading if you’re a doctor.

And maybe of some interest even if you’re not.

Following this year’s successful launch of the Choosing Wisely Australia campaign by NPS Medicinewise, we have produced a second round of recommendations about unnecessary tests, treatments and procedures.

I chair the RACGP working group, and we have just shortlisted the  fifteen items shown below. Yesterday we sent the list to all RACGP members for a ‘top five’ vote, although many wanted to vote for all 15!

This is part of the important conversation among doctors and patients that sometimes, less is more. Over-testing and over-treating can harm patients both directly, and also by robbing time and resources that would be better spent on things that are actually helpful.

No surprise if some items are a tad controversial – we have deliberately focused on tests and treatments that are commonly used by Australian doctors.

Screening

  1. Don’t routinely perform a pelvic examination when doing a Pap smear or prescribing an oral contraceptive
  2. Don’t advocate screening mammography in women < 50 yo or > 74, unless high-risk
  3. Don’t order colonoscopy as screening test for bowel cancer in the 98% of population where faecal occult blood testing (FOBT) is recommended

Imaging

  1. Don’t order shoulder imaging for straightforward shoulder pain, unless surgery is being contemplated
  2. Don’t order knee ultrasounds, nor ankle ultrasounds (except for achilles)
  3. Don’t order pregnancy dating scans unless there is doubt about a woman’s dates
  4. Don’t order chest x-rays for acute bronchitis unless bacterial pneumonia is suspected and the CXR will alter your management

Pathology

  1. Avoid unnecessary screening tests in pregnancy. Unless targeted reasons, don’t order ELFT, thalassaemia screen, full iron studies [ferritin alone is more useful], toxoplasma or listeria
  2. Don’t screen thyroid function on a healthy population
  3. Don’t order herpes simplex serology

Treatment

  1. Don’t routinely tick ‘no brand substitution’ on prescriptions. Exceptions may include; specific patient preferences or potential confusion
  2. Don’t treat otitis media with antibiotics, in non- Indigenous children aged 2-12y, where reassessment is a reasonable option
  3. Don’t treat osteoporosis without doing a fracture risk assessment, and explaining risk-benefit to the patient in absolute terms
  4. Don’t use antipsychotics in older patients for insomnia or dementia, without regular reviews that consider deprescribing
  5. Don’t recommend chelation therapy except for documented metal intoxication, diagnosed using validated tests in appropriate biological samples

Further recommendations:

Click here to see the list of 28 items we considered for the first round of recommendations earlier this year. Five made the final cut.

About Dr Justin Coleman

Justin is a GP working in Aboriginal health in Brisbane, Australia. He is also a medical writer, editor and blogger. Further details at https://drjustincoleman.com/
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3 Responses to Fifteen things good doctors should avoid – Choosing Wisely II

  1. cabrogal says:

    A good start Dr C but way short of adequate.

    How about “Don’t order PSAs for asymptomatic patients”? Or “Don’t prescribe antipsychotics for anything other than acute psychotic episodes and even then with a withdrawal plan in place”? Or “Don’t prescribe drugs that are new and heavily promoted when there are alternatives that are better studied and understood”? Or “Never prescribe antidepressants for those with bipolar and presume against prescribing them for anyone under 40 or who isn’t severely depressed”?

    I could go on. For a long time.

    Another one might be “Don’t start a group advising on medical treatment unless you can and will prominently display all its potential links with pharmaceutical and medical supply companies”.

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