Unnecessary medical tests need a rethink

Canadian doctors and patients should start talking about unnecessary tests and treatments to help make smarter choices and avoid potential for harm, a journal commentary says.

Choosing Wisely Canada is a new campaign meant to encourage awareness and discussion between doctors and patients about unnecessary tests, procedures and treatments.

"For many years, both physicians and patients have had a 'more is better' attitude," Dr. Wendy Levinson and Tai Huynh of Choosing Wisely Canada said in Tuesday's issue of the Canadian Medical Association Journal. "It is time to adopt a 'think twice' attitude and to avoid unnecessary and potentially harmful tests, procedures and treatments."

Patients may come in with an expectation, such as wanting a CT scan for a headache because that's what a neighbour received. But the patient may not realize that getting tests can lead to more tests or even invasive procedures that in the end reveal nothing, said Levinson, chair of Choosing Wisely Canada.

"The goal of this is about good care, the right patient getting the right test and avoiding unnecessary tests. It is not primarily about cost reduction," Levinson, also a professor in the department of medicine at the University of Toronto, said in an interview.

"You want patients to trust you that you're not withholding something they need, but your recommendation is based on what is good quality care."

She pointed to several factors on the medical side that can also contribute to unnecessary tests and procedures:

• It can be harder to explain to a patient why they don't need a test than to just order it.
• Fear of litigation.
• A practice pattern where "every time I see this condition, I order this test."

The Canadian campaign follows in the footsteps of Choose Wisely, which launched in the U.S. in February 2012.

In the U.S., specialists created lists of what doctors and patients should question, based on evidence of overuse, waste and potential harm.

Examples from the American Academy of Family Physicians' list include:

• Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
• Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
• Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

In Canada, 24 specialist societies are working on their own lists. In April, eight groups, including general surgeons, radiologists, and a family practice forum, plan to release their lists. Levinson said many of the Canadian societies looked at the American version to get started and then kept or modified items based on what is appropriate here.

Medical schools are an important part of the Canadian campaign, Levinson said, since learners may lean on unnecessary tests because they wish to be thorough and classes rarely discourage ordering extra tests. That culture is already changing, she said.

The Canadian group plans to evaluate the success of the campaign to understand its impact.

In the U.S., Consumer Reports partnered with Choose Wisely to get the word out. So far, the campaign has been received positively by medical societies and patients, said Dr. John Santa, director of Consumer Reports Health Ratings Center in Yonkers, N.Y.

Doctors and patients "need to talk to each other honestly about what's going on here and what they need and what they don't need and what's safe and what's risky and what helps and what could actually hurt," Santa said.