Choosing Wisely with The Naked Doctor

In his latest post for Croakey, The Naked Doctor, Justin Coleman, previews the Choosing Wisely campaign, due to launch in Australia in April.  This campaign focuses on cutting down the numbers of unnecessary medical tests and treatment and has been successful in the USA and Canada in reducing non-evidenced based interventions.  While a number of medical colleges have been involved in developing the Choosing Wisely campaign in Australia, this post discusses the Royal Australian College of General Practitioners’ input which focuses on primary health care and will identify five treatments routinely provided in general practice which are not supported by evidence.     

This post is the first in a series that Croakey will be running on Choosing Wisely which, as the Naked Doctor suggests, may make some controversial and confronting recommendations about current medical practices but which has the potential to both increase patient outcomes and save resources.  He writes:    

The Naked Doctor has always prided himself on choosing wisely – except perhaps his clothing choice in inclement weather – so it comes as no surprise that he has embraced Australia’s very own Choosing Wisely campaign, as others might embrace their warm jackets in winter.

This doctor has long recognised the imperative to strip his practice bare of any habit that research demonstrates is probably unhelpful to his patients. He is by no means alone, although, as we shall see, to go naked is to expose oneself to the pricks and barbs of one’s heavily insulated colleagues.

The NPS MedicineWise Choosing Wisely Australia initiative imports the 2012 US Choosing Wisely concept, where medical colleges are invited to highlight tests and treatments that are used widely despite evidence to the contrary. 

Canada’s Choosing Wisely (CW) campaign followed their Southern neighbour’s, and the movement is now spreading to 12 countries, including both England and its former convict outpost down under.

The primary concern is patient safety – always a relative concept, because at every juncture where a health professional must choose whether or not to intervene, neither path is absolutely safe. ‘First, do no harm,’ is an optimistic contraction of the full adage, which should continue, ‘…unnecessarily. Second, commence damage control!’

If the safer choice is obvious, no problem; read about it in any medical ‘how-to’ manual.

But the CW initiative consciously seeks situations where the safer direction might be down the road less travelled. Happily, each medical college gets to write its own signposts to guide doctors at the crossroads; bureaucrats and bean counters are denied access.

I chair the RACGP arm of the CW initiative, and it has fast become apparent that GPs are swamped with such decisions every day. With little trouble, we came up with an initial list of 28 suggestions from which just five will be detailed for publication at the CW launch in April. These are 28 situations where we believe the evidence suggests GPs should avoid a particular test or treatment.

Heavily represented among the 28 are tests ordered as a ‘screen’ in someone with no specific reason to have the test done. Healthy pregnant women getting tests of their kidneys, liver and various rare infections. Older people having cancer screening tests added in, “just to be sure, while you’re having the blood taken anyway.” The most notorious of these is prostate screening using PSA (detailed in my very own NPS MedicineWise PSA video), but others abound.

Doctors who believe they are going the extra mile for their patients by routinely recommending screening mammograms for women in their forties are presumably well-intentioned, but are probably walking that extra mile down the wrong track.

Some investigations on the list are being ordered for specific symptoms. X-rays and CTs for back pain have long been demonstrated to be unhelpful in all but a very few cases, yet, as inexplicably as a Miley Cyrus song, these investigations still manage to hang near the top of the ‘Hottest 100’ request list.

Ultrasounds are over-ordered for sore shoulders, twisted ankles and early pregnancies, while knee ultrasounds do little more than confirm that the patient still has a knee.

Various pharmacological treatments also score a mention, and that’s even without Vit D and testosterone making our cut. We felt that avoiding antibiotics for viral respiratory infections was too obvious, but acute sinusitis still warrants its own antibiotic caution, as does middle ear infection in many situations.

If some of items on the list surprise you – or even annoy you—rest assured you are not alone. After all, one of the list criteria was that many doctors do actually order the test or treatment. The Naked Doctor doesn’t shy from controversy, even if he occasionally shivers within its cold embrace.

Why, the very first online doctor’s response to the list was, verbatim, “No imaging for back pain! Do you have X-ray vision? Surely you must be kidding? I’m glad you’re not my doctor.”

Not as glad as I am, although I may have enjoyed eyeing him from the edge of the bed and claiming I could see right through him. At least we now know who’s still ordering all those back X-rays.

Other, more reasoned critics have queried the GP focus, given specialists overtest and overtreat at least as often – but the specialist colleges’ lists should balance this out. And the list of Don’ts has been described as sounding overly negative – perhaps a valid criticism of the CW nomenclature.

We doctors are pretty comfortable navigating pathways of how to investigate and treat patients, but may have more trepidation taking the route which avoids intervention, especially if it is trivialised as ‘the road to nowhere’. Expect plenty of robust discussion in April, when Choosing Wisely launches its new road map.

Justin Coleman is a GP who blogs at The Naked Doctor and a regular contributor to Croakey.