This is not a (necessary) test

April 5, 2012 9:09 PM

Choosing Wisely encourages physicians and patients to discuss whether certain medical tests and procedures are unnecessary, especially those that can cause harm. The site offers nine lists of Five Things Physicians and Patients Should Question about the most appropriate care for a patient, including lists for cardiology and oncology.

More lists are due in fall 2012.

Choosing Wisely aims to help patients choose care that is:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

Consumer Reports will be distributing materials to patients through large consumer groups to help patients have these conversations with their physicians.

It's a project of the ABIM Foundation (ABIM being the American Board of Internal Medicine, as I discovered after rather more poking around than necessary).

posted by kristi (33 comments total)

I often hear radio ads for companies that will do full body scans, which of course are not covered by any insurance. They often have a testimonial from someone who has used their services and was saved because a tiny tumor was found way before any symptoms were present. As an avid hypochondriac, I'm often tempted to look into the services, but the rational side of me knows that going down that path only leads to more and more tests. Once they have you under their scanner, they know how to keep you there and rack up the test fees.
posted by crunchland at 9:21 PM on April 5, 2012 [4 favorites]

I strongly applaud the spirit behind this, but they seriously need to rewrite these with patients in mind. Here's one of the Five Things Physicians and Patients Should Question from the American College of Physicians list:

"Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology."

I'd estimate that's at a college-graduate reading level, and needlessly so (intrathoracic? seriously? I know what that means, but it's not even in my dictionary). How about:

"Don't order a chest X-ray before an operation unless there are symptoms of heart or lung problems."

It conveys essentially the same information and is vastly easier to understand. If you're trying to encourage communication between doctors and patients, it's probably a good idea not to use a bunch of medical jargon, especially when it isn't actually necessary.

Nothing says useful information like downloadable PDFs.

I suspect they're meant to be turned into posters or tacked up on bulletin boards.
posted by jedicus at 9:21 PM on April 5, 2012 [12 favorites]

I want a full body MRI, but I want the raw data too (and a program to read it, of course). I am not looking for anything specific, just for the plain fun of having the raw data for my own education and curiosity.

I know there is a small risk of an allergic reaction to the contrast agents, but as I don't seem to have any allergies anyway, the risk is acceptable. I'm glad I would have to go outside my existing insurance to get one, as I'd rather not have that data used later on as possible leverage to deny coverage. I would want sole ownership of the data and the knowledge of its existence. Later, if something arose that would actually require a MRI, I would have a previous data set to provide for comparison.

Also, I'm aware that it's not the best detector for everything, and the many things that show up that may indicate something, but really aren't an issue, as bodies are weird and full of odd little anomalies.

Maybe it's a bit narcissistic, and about as close to literal 'navel gazing' as you can get, but I'd really find it fascinating.
posted by chambers at 9:38 PM on April 5, 2012 [2 favorites]

Remember that the real Grail looks like a carpenter's cup.
posted by XMLicious at 9:41 PM on April 5, 2012 [3 favorites]

they seriously need to rewrite these with patients in mind

These are written for providers. To write them for patients, they'd each have to be 15 pages long.
posted by neuron at 10:03 PM on April 5, 2012

...and then they could put them up on cracked.com.
posted by crunchland at 10:05 PM on April 5, 2012

Huh. No organizations specific to women's reproductive health. Weird.
posted by desuetude at 10:21 PM on April 5, 2012 [1 favorite]

...and rack up the test fees.

And the cumulative genetic damage!
posted by clarknova at 10:30 PM on April 5, 2012 [1 favorite]

I want a full body MRI, but I want the raw data too (and a program to read it, of course). I am not looking for anything specific, just for the plain fun of having the raw data for my own education and curiosity.

Me too. My SO has had a few imaging-type procedures done in the last few years, and always asks for a copy of the data. It's like any of your other medical records; the hospital will give it to you for the cost of duplication, which in this case means they burned a CDROM with the files and a small viewer program for the file format (DICOM, I think, nothing too obscure). The data's fun to play with.
posted by hattifattener at 10:34 PM on April 5, 2012 [2 favorites]

Great to know about what tests not to take unless necessary, especially when they involve radiation or involve tremendous risk.

Inversely, it's also good to be able to order blood tests on one's own, very cheaply, without a doctor's prescription. Life Extension Foundation's blood tests are excellent and really affordable. This is very practical for a person who does not have insurance.

Example: CA-125 test $81 bucks
CEA test $37.33
Carbohydrate Antigen 19.9 test $110.67

Anecdote: A year after chemo ended I had, among many side effects, such as feet that felt like blocks of cement and walking felt like on crushed glass (neuropathy), all kinds of itchy and weird skin conditions, 4 aneurysms (subarachnoid bleeds) in 12 days.

These aneurysms (subarachnoid hemorrhages) were serious agony, the most pain I've ever experienced. They say a subarachnoid hemorrhage is the worst headache of one's life but that's really nothing what it's like. It's like the World Trade Center falling down in one's head, involuntary non-stop screaming, passing out from the pain kind of thing.

In spite of my telling them my medical history of having been recently treated for cancer with chemo and radiation, none of the docs could figure out what these aneurysms were from. They all seemed totally mystified. They gave me a very risky test, brain surgery basically, a brain endoscopy that meant putting a probe into my brain. I had to sign papers that it wasn't their fault I came out a vegetable.

Several lumbar punctures. 2 CT scans then an MRI. Then my neurologist wanted me to do a really risky test, that involved stopping my heart momentarily. I can't remember the name of the test. I think it was Transesophageal Echocardiography.

The chances of surviving just one of these aneurysms isn't good: > "An estimated 10-15% of patients die before reaching the hospital. Moreover, mortality rate reaches as high as 40% within the first week, and about 50% die in the first 6 months." So I felt forced to take this dangerous test.

After analyzing my situation myself logically, looked at when the aneurysms happened and the relief I experienced in the Emergency Ward when I'd been injected with magnesium. I googled magnesium and realized it's help in treating constipation. I'd been constipated for over a year from the chemo and pain meds for the chemo pain. I realized I had these aneurysms after trying to go to the toilet, from straining. The neurologist didn't want to hear about constipation, her specialty was the other end of the body, the brain not the poop chute. None of the docs asked me about constipation, which is a typical, predictable side effect of chemo.

So I self medicated with magnesium citrate, which relieves constipation in a different way that laxatives, it brings water into the colon, which helps the evacuation process a lot. Calcium and magnesium citrates combined, to be exact. And that did the trick, instantly. No more aneurysms. No more dangerous tests. No more brain surgeries.

tl;dr Almost died from aneurysms, doctor's tests increasingly risky and not helping. Self medicating with magnesium did the trick.
posted by nickyskye at 12:03 AM on April 6, 2012 [21 favorites]

Primum non nocere.
First, do no harm.

Cynically, I feek the priorities have shifted in today's big pharma and big med dominated world:\

1) Profit
2) Crush your enemies -- See them driven before you, and hear the lamentation of their women
3) Dramatize efficacy and mask that which is statistically insignificant.
4) Profit
5) Profit
posted by isopraxis at 12:33 AM on April 6, 2012 [1 favorite]

Then my neurologist wanted me to do a really risky test, that involved stopping my heart momentarily. I can't remember the name of the test. I think it was Transesophageal Echocardiography.

I'm pretty sure they don't even come close to stopping the heart during a transesophagel echo. All I read in the descriptions is some mild sedation. You might not even be all the way under.

I just don't want someone googling the procedure and getting the wrong impression from your comment. It sounds fairly risk free.
posted by sbutler at 12:42 AM on April 6, 2012 [1 favorite]

Meanwhile my insurance has denied an MRI that I actually do need, probably because my neck pain can be managed (sort of) with painkillers. Never mind that my last MRI possibly showed a build up of fluid in the spinal cord that potentially leads to paralysis if untreated.
posted by desjardins at 1:11 AM on April 6, 2012

Most of these things are a distorted way of saying "Use statistics to save money." It should be, "Use statistics, but don't ignore your instincts."
posted by Drumhellz at 1:16 AM on April 6, 2012 [1 favorite]

Hm... The list from the American Academy of Family Physicians says pap smears shouldn't be done on anyone under 21. I've always thought that you should start getting regular pap smears when you become sexually active or turn 21, whichever comes first. My GP recommended starting them earlier because I have a family history of irregular smears and cervical cancer. That was years ago, so I understand that the recommendations may have changed, but I thought they would have moved toward more screening given the research linking HPV and cervical cancer. Unless the HPV vaccine is now manditory for kids these days?
posted by youngergirl44 at 1:19 AM on April 6, 2012

desjardins, don't you just love that? If a pill works, who cares about the cause?

[just grumbling from my own recent experiences with trying to get some help medically]
posted by [insert clever name here] at 1:19 AM on April 6, 2012

Links to decision guides aimed towards patients. (via)
posted by klarck at 4:18 AM on April 6, 2012 [1 favorite]

6)The best diagnostic test is an autopsy; in the event of your death, would you like one?
posted by Renoroc at 4:49 AM on April 6, 2012 [1 favorite]

MORE PROOF THAT HOMEOPATHY WORKS!
posted by spitbull at 5:09 AM on April 6, 2012

The list from the American Academy of Family Physicians says pap smears shouldn't be done on anyone under 21. I've always thought that you should start getting regular pap smears when you become sexually active or turn 21, whichever comes first

The reason for this delay in pap smears testing or the (almost) equivalent HPV testing is that the female body is able to clear up HPV infections easily enough without medical interventions before age 30. This link from the CDC gives a lot of details on paps and liquid HPV testing.
posted by francesca too at 5:19 AM on April 6, 2012

I have a test-happy doctor. I went in recently for a physical, and for a while, it was looking like seven separate visits, for blood tests, x-rays, pap smears, the whole kit and kaboodle. Just after scheduling all this, the Globe and Mail ran an article in which the College of Physicians basically denounced this kind of repeated visits to get a single procedure dealt with. My roster of seven visits quickly and inexplicably dropped to two.
posted by LN at 5:46 AM on April 6, 2012

Does posting on AskMefi count as a test?
posted by JoanArkham at 5:50 AM on April 6, 2012 [1 favorite]

As a soon-to-be physician (in Canada), the fact that there needs to be lists of Thou Shalt Nots like these really confirms some of the worst stereotypes we have about American medicine. Not that we don't have test-happy docs here, as LN says. But some of these make me just shake my and head and mutter to myself. I guess the upside of having limited resources is that you're forced to be more prudent and evidence-based.
posted by greatgefilte at 5:53 AM on April 6, 2012 [2 favorites]

As a soon-to-be physician (in Canada), the fact that there needs to be lists of Thou Shalt Nots like these really confirms some of the worst stereotypes we have about American medicine.

Yeah, I am reading this in Australia and confused that cardiac stress testing or ECGs are even considered reasonable screening tests.
posted by chiquitita at 6:14 AM on April 6, 2012

As someone relatively new to chronic illness and has had well too many tests over the last year, it's going to take some exploration of this material to understand the advice and value. I know personally that I've challenged and rejected some testing that after discussion my doctors agreed wouldn't change current treatment or prognosis, independent of findings. I'm probably close to cancelling another set of tests and a followup appointment with a specialist as in my own sense it's liable to show a negative result. If it is what they are looking for, it should show itself in other ways in any instance.

But a lot of this assumes an active relationship with a primary physician that goes beyond a lot of most peoples history. It's really hard to maintain this level of dialogue when appointments might be a month apart in the best of cases.
posted by michswiss at 6:27 AM on April 6, 2012

I am reading this in Australia and confused that cardiac stress testing or ECGs are even considered reasonable screening tests.

Because in the US many doctors own the test equipment. Gotta get some use out of that investment, you know?
posted by Johnny Wallflower at 7:52 AM on April 6, 2012

kristi: "ABIM Foundation (ABIM being the American Board of Internal Medicine, as I discovered after rather more poking around than necessary)."

Thank you for that comment. Prior to reading it, I was beginning to think I was extraordinarily dimwitted while I was trying to find out from their own site what the heck that acronym meant. (I never did find it on their site, so I had to resort to google.)

I also have to say how much the links included in the FPP made me wonder whether this advice was, in fact, in the best interests of patients, or in the best profit interests of insurance companies here in the USA. Looks like the former to me from reading the mefi comments, so that was a relief.
posted by InsertNiftyNameHere at 9:35 AM on April 6, 2012 [1 favorite]

desuetude: "Huh. No organizations specific to women's reproductive health. Weird."

Yeah, that was one of the first things I looked for. I'm hoping that will be one of the new lists available in the fall.

InsertNiftyNameHere: "I also have to say how much the links included in the FPP made me wonder whether this advice was, in fact, in the best interests of patients, or in the best profit interests of insurance companies here in the USA. Looks like the former to me from reading the mefi comments, so that was a relief."

Yeah, I know what you mean, and that was one of the reasons I made a point of finding out who ABIM is - I would have had a different impression if the site was sponsored by the American Bureau of Insurance Magnates. In a way, though, it seems to me that there will always be cost-benefit decisions involved in health care, whether it's paid for by insurance companies, the government, or individuals - and the more we can base those decisions on medical evidence, the better.
posted by kristi at 10:30 AM on April 6, 2012

youngergirl44 - francesa too is totally on the money. actually, the guidelines have changed again recently! part of the problem is high positives with cervical cell abnormalities....when a healthy young woman is going to clear/manage the virus within a couple of years and it's fine. a lot of times people go straight to colposcopy too, when it could be managed just by serial cytology (english: getting a pap at 6 and 12 months after the abnormal). i have a lot of gripe with paps as commonly performed. you don't need it every year (unless you had to have treatment for an abnormal). cervical cancer is so vanishingly uncommon amongst 20 - 30 year olds that doing it every year is major overkill. there's basically no genetic component, it's HPV that's the culprit...it also is overwhelmingly very slow growing. man, i have such a soapbox on this issue, sorry.

but yeah, overdoing tests - example, one of my friends is at a clinic where the doctor does a chest x-ray on EVERY SINGLE NEW PATIENT. "juts as a baseline!!!". this is mind-blowing to me. any surprise that the x-ray machine is in-house? ...
posted by circle_b at 10:48 AM on April 6, 2012 [2 favorites]

er, "just".
posted by circle_b at 10:50 AM on April 6, 2012

One thing you can do, as a patient, to cut down on unnecessary tests is to request and keep a copy of all your test results. Doctors and hospitals are pretty bad, in my experience, at sharing information, even though both law and custom (professional courtesy) demand it. And many places now destroy records after only 7-10 years (depending on the state; some states thankfully require longer retention policies), when they can still be clinically useful -- particularly if you have a slow-moving condition of some sort, or an issue that resolves itself but later flares back up.

More than once I've been in to see a new doctor for something, and had them sign me up for a whole panel of tests that a previous doctor had just run. It's worth asking, if you're in that situation, whether they're aware of the previous test. Sure, there may be legitimate reasons for running them again, but sometimes it's duplicative. And even if it turns out that the new ones are necessary, the new doctor will have one more datapoint to compare to.

Even if you can't do much with the records yourself (e.g. DICOM or proprietary radiology films), you can at least keep them handy to give to another doctor.

Given the utter lack (and little realistic prospect) of any sort of centralized medical-record system in the U.S., your best bet is to just keep copies of everything yourself, and then provide copies to each new provider you see who wants your history.
posted by Kadin2048 at 11:24 AM on April 6, 2012 [2 favorites]

I find cost-effectiveness an exquisitely touchy subject to broach with patients.

A 35 year old patient asked me to test his cholesterol. He wanted "screening blood tests" just to make sure everything was ok.

I had the conversation with him that, in the absence of symptoms, there's no real indication to do any blood tests in a healthy young male.

And he said: isn't there a chance you'll find something abnormal?

I answered with the requisite yes, even if there is, the odds are that it will be a false positive and invite undue amounts of anxiety, cost, and possibly invasive tests.

And he said, I'm ok with that.

Trying to distil population-level reasoning into the one-on-one doctors offices is not always easy.
posted by cacofonie at 8:09 AM on April 7, 2012

nickyskye: I realized I had these aneurysms after trying to go to the toilet, from straining. The neurologist didn't want to hear about constipation

Intrancranial aneurysms are not caused by straining to evacuate your bowels. There are several layers of autoregulation between your intrathoracic and abdominal cavities and your brain.

CPP = MAP − ICP

Evacuation straining probably raises the likelihood of diverticulosis.

Intracranial aneurysms have many causes, none of which involve straining to poop. Causing an existing aneurysms to rupture, however, may be influenced by transient and extreme increases in MAP +/- deficiencies in cerebral blood flow autoregulation.

I am a physician, but I am not your physician and these statements of fact do not constitute medical advice or create a physician-patient relationship.
posted by meehawl at 1:54 PM on April 7, 2012