Choosing Wisely, and the choices ahead.

Jan. 23, 2017
The Choosing Wisely campaign, an effort of the American Board of Internal Medicine (ABIM) that began in 2012, is important and valuable. In healthcare as in everything else, too much is done because it has “always” been done that way, and procedures should be under constant review. Such ongoing evaluation can only make healthcare more effective and efficient, benefiting patients, practitioners, and the healthcare system alike.

The campaign has been widely publicized, including in these pages from time to time, and it came to my attention again when I read online an excellent article “40 common treatments and tests that doctors say aren’t necessary,” by Serina Sandhu (https://inews.co.uk/essentials/news/health/40-treatments-doctors-saying-bring-little-benefit/). The article summarizes some of the advice given by the Choosing Wisely campaign.

Some of the items that relate to lab testing, and I quote:

  • People should undergo calcium testing only when there are symptoms of kidney stones, bone disease or nerve-related disorder.
  • For women over the age of 45, a blood test is not needed to diagnose menopause.
  • A vaginal swab is not usually necessary for women who have abnormal vaginal discharge likely to be caused by thrush or bacterial vaginosis (and if she is at low risk of having a sexually transmitted infection).
  • If people take a statin at the recommended dose, there is usually no need to
    routinely check cholesterol levels.
  • Prostate-specific antigen (PSA) screening does not lead to a longer life unless a person is at risk of prostate cancer because of race or family history.
  • Transfusing platelets for people with chemotherapy-induced thrombocytopenia (deficiency of platelets in the blood) should only be considered where the platelet count is < 10 x 109/L (except in certain situations).
  • O RhD negative red cells should only be transfused to O RhD negative patients, as well as in emergencies for women of childbearing potential with an unknown blood group.

Some of the above is controversial—the ongoing discussion about prostate cancer screening, for instance—but the idea is to get the conversation going. Another lively controversy concerns testing for cervical cancer: when it should begin, at what intervals, and whether the Pap test should be accompanied by HPV testing.

Beyond that, the whole topic of testing and screening may have a new urgency in the light of the Republican victories in the 2016 presidential and Congressional elections. With majority control of both houses of Congress and with the election of President Trump, the GOP will soon—perhaps by the time you read this—achieve its goal of repealing the Affordable Care Act (ACA). Whether it will be wholly repealed, or repealed in parts, or perhaps parts of it will be repealed and others allowed to stand, and what the pace of all this will be—all of that is to be determined. But, in any case, one important part of Obamacare was making preventive tests more affordable for more people, on the theory that this would not only save lives but money: it is less expensive to catch colon cancer before it metastasizes than to treat it after. Statistics indicate that screening rates did go up significantly for mammography, for instance, but very little if at all for colonoscopy. As for conventional lab tests, it stands to reason that insured people are more likely to have wellness checkups, which often include at minimum the CBC.

It appears that the ACA will be repealed, more or less, and probably replaced, more or less, with a system that reflects the Republican preference for free-market approaches over the Democratic tendency to favor federal government programs. Whatever happens, though, both parties in Congress and the new president should not allow life-saving, needful testing to fall through the cracks. At the same time, clinicians should Choose Wisely, and avoid overtesting. In fact, it is a delicate balance, perhaps especially so in these uncertain times.