Recently, there has been much debate and controversy over when and if certain medical tests should be ordered, including mammograms, Pap smears and PSA screening for prostate cancer. Being that we are experiencing an increase in overall health care expenditures, numerous organizations have come together to try and identify areas in which we can reduce our medical testing and spending.
The Choosing Wisely campaign is one such initiative by the American Board of Internal Medicine, the American Academy of Family Physicians and Consumer Reports. This campaign aims to provide care that is supported by evidence, doesn’t replicate other tests or procedures already received, is free of harm and is genuinely necessary.
Medical specialists across the United Sates have identified a list of “Five Things Physicians and Patients Should Question,” designed to highlight the need/lack thereof for many frequently ordered tests or treatments:
1. Don’t do imaging for low back pain within the first six weeks, unless red flags are present. These warning signs include severe or progressive neurological deficits or when serious underlying conditions are suspected. Virtually all people over 50 will have abnormalities on such tests, and most back pain improves without surgery.
2. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for 7 or more days, or symptoms worsen after initial clinical improvement. Most sinusitis is due to a viral infection that will resolve on its own.
3. Don’t use dual-energy X-ray absorptiometry “DEXA” screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. It is NOT effective in younger, low-risk patients.
4. Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. Potential harms from this test outweigh the potential benefits. It has not been proven that detection of coronary artery disease in asymptomatic, low-risk patients improves health outcomes. False positive results often result in unnecessary invasive procedures, over-treatment and misdiagnosis.
5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Most abnormalities in women younger than 21 will regress on their own. Pap smears in women who have had a hysterectomy are not helpful.
While the Choosing Wisely recommendations are widely established, other tests remain the topic of much debate. Until the usage of these other tests is agreed upon, physicians should focus on individualized care. Instead of prescribing the same battery of tests for every patient, physicians should consider the patient’s family and personal histories and their ultimate treatment goals.
As a urologist, the only screening methods we have for prostate cancer have also come under scrutiny: PSA tests and digital rectal exams (DRE). Although individually each of these exams is not very sensitive in detecting prostate cancer, together they allow doctors to better identify those at risk. While the actual PSA result is not always critical to prostate cancer detection, the trend and velocity at which PSA changes is critical to detection. Patients and clinicians need to be educated that not every high PSA requires a biopsy, and subsequently not all prostate cancers require treatment. This is reflected in the recommendations released by both the American Urological Association and American Cancer Society, which focuses on informed decision making.
The debates surrounding the utilization of these tests will not be resolved overnight. Doctors have become accustomed to performing these rituals in their years of training, and patients have come to expect it. My best advice is to take care of yourself; eat healthily and in moderation, exercise and find time to relax. Be your best doctor.