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.
- Don’t routinely perform a pelvic examination when doing a Pap smear or prescribing an oral contraceptive
- Don’t advocate screening mammography in women < 50 yo or > 74, unless high-risk
- Don’t order colonoscopy as screening test for bowel cancer in the 98% of population where faecal occult blood testing (FOBT) is recommended
- Don’t order shoulder imaging for straightforward shoulder pain, unless surgery is being contemplated
- Don’t order knee ultrasounds, nor ankle ultrasounds (except for achilles)
- Don’t order pregnancy dating scans unless there is doubt about a woman’s dates
- Don’t order chest x-rays for acute bronchitis unless bacterial pneumonia is suspected and the CXR will alter your management
- 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
- Don’t screen thyroid function on a healthy population
- Don’t order herpes simplex serology
- Don’t routinely tick ‘no brand substitution’ on prescriptions. Exceptions may include; specific patient preferences or potential confusion
- Don’t treat otitis media with antibiotics, in non- Indigenous children aged 2-12y, where reassessment is a reasonable option
- Don’t treat osteoporosis without doing a fracture risk assessment, and explaining risk-benefit to the patient in absolute terms
- Don’t use antipsychotics in older patients for insomnia or dementia, without regular reviews that consider deprescribing
- Don’t recommend chelation therapy except for documented metal intoxication, diagnosed using validated tests in appropriate biological samples