“Choosing Wisely” is anything but wise

DRUG BUST by Alan Cassels

• The people’s briefing note on prescription drugs

If you want some reliable advice about which medical procedures, screening tests or drug therapies are unnecessary, useless or even downright dangerous, one of the best sources is the medical professionals themselves. After all, the people delivering the procedures and prescribing the tests or drugs are best situated to determine which of them are a waste of time and possibly harmful to the patient.

Let that thought sink in for a moment, then ask yourself, “Is Alan losing his marbles?” I’m not. At least, I think I’m not. But to suggest it’s fruitful to ask people who deliver services to tell you which ones are dangerous, stupid or wasteful overlooks one very keen principle of human nature: Economic self-interest.

It’s not really fair to ask for an objective opinion from anyone who has a vested interest in what they’re selling. How about the sales clerk in the vitamin store, the investment broker or your barber? Do they ever say you need ‘fewer’ of their services? Economic self-interest is a powerful motivator and we shouldn’t expect people to act differently when defending medical practices and promoting their own ideas. After all, they too have to feed their children.

But this is exactly what we are seeing happening with the recent “Choosing Wisely” campaign (www.choosingwisely.org), which, on the face of it, is an extremely beneficial exercise. The campaign aims to get medical specialists themselves to answer the question, “What medical care are you routinely providing that is mostly unnecessary and possibly harmful?”

This is what I’d call the ‘blood letting’ question, which conjures up images of the many barbaric things that state-of-the-art medicine delivered in the name of patient care 50 or 100 years ago. Think of electro-shock therapy, heroin-laced cough syrup, thalidomide for pregnant women, lobotomies and so on. The list of blood-letting procedures looks very long in hindsight.

“Choosing Wisely” was created in the US by the ABIM Foundation (American Board of Internal Medicine) recognizing that the concept of “too much medicine” is starting to go mainstream and that even consumers are demanding that medical specialties start assessing which services they deliver that could be deemed potentially useless, unnecessary or harmful. The ABIM has asked dozens of specialty organizations in the US (and now in Canada) to put forward lists of the five “Things Physicians and Providers Should Question.” For the Canadian take on things, visit www.ChoosingWiselyCanada.org to see what’s on the list so far.

On the site, you’ll find the Canadian Medical Association’s Forum on General and Family Practice (overseeing the care delivered by your family doctor). Their list of the “Five Things Physicians and Patients Should Question” includes:

Don’t do imaging for lower-back pain unless red flags present.

Don’t use antibiotics for upper respiratory infections (i.e. colds or flus likely due to viruses).

Don’t give X-rays or ECGs for asymptomatic or low-risk patients.

Don’t give Pap smears to women under 21 years of age or over 69 years of age.

Don’t do annual blood screening tests unless directly indicated by the profile of the patient.

Not a bad start, methinks, yet I wouldn’t classify these “Don’t Do’s” as low-hanging fruit; they’re more like fruit that’s rotting on the ground. In the interests of collegiality, let’s cut the College of Family Physicians some slack and give them one gold star for at least starting the discussion: “Attaboy. Keep at ‘er.”

Now you’re wondering, “What is on Alan Cassels’ list?” That’s a good question because over the last 20 years, I’ve often spoken and written about the gap between medical evidence and medical propaganda. I’ve found over that time lots of medical care not supported by good evidence, but it’s actually difficult to come out with a blanket condemnation on what specifically constitutes useless, unnecessary and possibly harmful medical care. My “Don’t Do” list for family doctors (or, at least, things doctors and patients should question) is below and I’m inviting anyone who disagrees with me to write me and explain why they disagree:

1. Don’t order annual physicals for healthy people. The ritual of patients showing up every year for an ‘annual checkup’ when already feeling perfectly healthy isn’t proven to contribute to the quality and length of patients’ lives. Sorry, at the same time, patients should see their doctor to get any symptom, worry or concern immediately checked out. Our docs are there to help determine what might be wrong and provide some signposts on how to fix things.

2. Don’t give statins (cholesterol-lowering drugs) to anyone unless the person can prove they have heart disease, understands the low possibility of benefit, has read a comprehensive list of statin-related adverse effects and begs politely for a script, using the term “pretty please with sugar on top.”

3. Don’t routinely offer a PSA test to otherwise symptomless, healthy men. Which is to say, stop offering a prostate screening test that is statistically more likely to ruin a healthy man’s life than save it.

4. Don’t routinely push women to get their mammograms done. The main exceptions here are women who have a strong family, genetic or personal history of breast cancer and who have read and understood fully the evidence around mammography and their chances of having a false positive, false negative or an unnecessary biopsy.

5. Don’t offer anyone – no woman, man or beast – a bone density test. This test will only add anxiety and fear to a person’s list of woes. It won’t prove anything and it won’t help anyone except by adding revenues to osteoporosis drug makers and companies that make and operate bone density test machines.

6. Don’t routinely offer pregnant women artificial labour induction – to speed up labour – if a woman seems to be a few days past her ‘due’ date. A pregnant woman is not a quart of milk that spoils after some arbitrary and unscientifically determined date. Artificial labour induction for an otherwise healthy pregnant woman with a normal pregnancy is a fast-track to a C-section.

7. Don’t routinely offer pregnant women the ‘choice’ to have a C-section. Unless there are strong medical reasons for one, the evidence says a Caesarean section is major abdominal surgery with potential for harms, complications and adverse effects for both mother and child. C-sections are valuable and lifesaving for some and shouldn’t be treated as a discretionary procedure.

8. Stop giving children antidepressants. Just stop. While pondering that thought, consider rereading the FDA’s or Health Canada’s warnings on SSRIs in children. There are many beneficial things medicine can do with troubled children, but feeding them antidepressants, statistically speaking, will increase the likelihood they’ll attempt suicide.

9. Stop obsessing about your patients’ blood pressure, especially in elderly people. In fact, for older patients who are otherwise well and stable, their slightly elevated blood pressure should not be cause for alarm; nor should it instigate constant checking and rechecking and the consumption of prescriptions for one, two or maybe even three antihypertensive drugs. This busywork to bring down the pressure to a ‘target’ level that someone has determined to be ‘normal’ is a pharmaceutical industry construct that continues to harm many people and break many hips.

10. For your patients who have type-2 diabetes and who seem to get along fine with no problems managing their blood glucose levels, stop urging them to frequently and obsessively test their blood sugars. The testing and retesting of blood sugars is as close to modern blood-letting as we can come and most people with uncomplicated diabetes should be able to control it with diet alone and older, proven drugs like metformin.

There, I’ve said it. That’s my list. “Ten things Alan Thinks Physicians and Patients Should Question.” While there may be some very good medical reasons why these things haven’t yet been nominated on the list created by Canada’s family physicians, let’s not assume economic self-interest is one of them. They’ve made a start and that’s good. Now, what’s on your list? Write me at alan@alancassels.com

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Alan Cassels is a pharmaceutical policy researcher in Victoria. He is seeking ways to convince people that consuming less medical care – the unnecessary, useless or harmful stuff – can be healthy. You can follow him on twitter @AKECassels or at www.alancassels.com