Choosing Wisely: Recommendations For Tests Not To Have

Dr. David J. Holcombe
Dr. David J. Holcombe

In this era of hi-tech medicine, there are a plethora of wonderful tests and procedures that your doctor can order.  Although it may seem intuitive that the “more the better”, that is not always the case.  Some tests may actually be dangerous, and many are very expensive.  Each time doctors order a test, the question should always be, “Do the benefits of the information exceed the risks (and the costs)?”  Since we are currently spending over 2.7 trillion dollars each year (over 16% of the gross domestic product) on medical care, the burden of that cost is crowding out other expenditures, and making the nation less competitive in global markets.  In addition, over 225,000 deaths a year are considered “iatrogenic” (related to medical care), and it is estimated that less than 20% of such cases are actually reported, making the real figure much higher.


The American Board of Internal Medicine (ABIM) asked doctors in various fields to list 5 tests that they felt should not be done, since the cost (or risks) did not exceed the expected benefits.  Although some of the tests and procedures are uncommon, many are very common and often considered “necessary”.  Following are a few of the selections from three of the leading medical organizations.


The American College of Physicians (ACP) did not recommend getting EKGs in individuals without symptoms and with low cardiac risk.  They did not recommend getting x-ray studies of the back in patients with non-specific back pain of short duration without neurological symptoms.  The ACP did not recommend chest x-rays in patients prior to surgery with no suspicion of thoracic problems.


The American Academy of Family Physicians (AAFP) did not recommend antibiotics for the treatment of sinusitis lasting less than seven days.  They did not recommend DEXA (bone density) screening in women less than 65, or in men less than 70 without risk factors.  The AAFP (and others) did not recommend Pap smears in women younger than 21, or women older than 65 with a normal prior test, or any woman after a hysterectomy.  The same group does not recommend induced labor or Cesarean prior to 39 weeks gestation without true medical indications.  The AAFP does not recommend screening carotid ultrasounds (looking for blockage in the arteries of the neck) in adults without symptoms.


The American Academy of Pediatrics (AAP) does not recommend antibiotics for viral respiratory illnesses in children.  They do not recommend cough and cold medicines for children under four years of age.  The AAP does not recommend a CT (or MRI) of the head for children with simple febrile (related to high fever) seizures.  Similarly, they do not recommend abdominal CTs for the routine evaluation of abdominal pain.


There are many more recommendations of tests not to perform listed under the “Choosing Wisely” list.  Before the uncertainty of medical situations and the constant dread of litigation, the tendency has been to perform tests that may not really be medically indicated.  The current program gives solid scientific justifications for these decisions to abstain from unnecessary testing.  Sometimes more is not better and, as always, the physicians’ mantra should be “primum non nocere” (first, do no harm), whether it be to the patient or the national debt.