The problem of questionable treatment and tests which may provide little or no benefit, yet may cause harm, is ubiquitous across all areas of health care.
Harm doesn’t just come in the form of side-effects or further testing. The “cons” of any treatment or test also include the costs, which can be financial, emotional, and the costs of the individual’s time.
The Choosing Wisely campaign encourages patients and clinicians to question unnecessary treatments. First launched in America in 2012 and in Australia last year, the clinician-led initiative collates lists of tests, treatments and procedures that provide little or no value, and which may cause harm.
Today the Australian organisers, NPS MedicineWise, will release an additional 61 recommendations. These include:
- Don’t order chest x-rays in patients with uncomplicated acute bronchitis (Routine chest x-rays don’t improve outcomes and may lead to false positives, further investigations and unnecessary radiation)
- Avoid prescribing antibiotics for upper respiratory tract infections, also known as the common cold (Most uncomplicated upper respiratory infections are viral and antibiotic therapy isn’t suitable)
- Don’t initiate medicines to prevent disease in patients who have a limited life expectancy (There is limited evidence to support the use of many medicines in frail, elderly patients who are more susceptible to the side-effects of medicines)
- Don’t routinely do a pelvic examination with a pap smear (The procedure can cause pain, fear, anxiety and embarrassment and can lead to unnecessary, invasive and potentially harmful diagnostic procedures)
- Don’t request imaging for patients with non-specific low back pain (Trials have consistently shown there is no advantage from routine imaging of non-specific low back pain and there are potential harms).
The need for informed conversations about potentially unnecessary treatments, tests and procedures is certainly not restricted to only the medical professions.
As well as the medical colleges and societies involved, it is encouraging that in this second release, organisations which represent nurses and allied health professionals such as physiotherapists and hospital pharmacists have participated. Hopefully in future releases, we will see more of Australia’s allied health organisations becoming involved in Choosing Wisely.
As with the 2015 lists, most of the recommendations are about doing less. Only a few are about encouraging a particular action to be done. An example is having an earlier conversation about prognosis, wishes, values and end of life in patients with advanced disease.
This may be because we clinicians are guilty more often of doing too much than too little.
This is counter-intuitive to most of us. Somehow, the thought that a clinician might have not done enough feels more reprehensible than their having done too much. And this is not just what patients might think – it’s probably true of many clinicians as well.
The memories of many junior hospital doctors probably include over-ordering tests (“just in case”, but also to demonstrate their knowledge of rare diagnostic possibilities) to avoid their seniors criticising them during an upcoming ward round.
The realisation that patients can actually be harmed more by receiving unnecessary tests, procedures, and treatments, than by not having received them has been painfully slow.
The Choosing Wisely campaign helps to signal a very important departure from normal business for clinicians and their organisations – thinking about not doing things.