Is "Choosing Wisely" (ordering less tests) legit or purely a money saving attempt?

[MedicineZ0Z]

From an individual patient care and liability standpoint - it makes more sense to order more tests (in general principle). But we have this notion being put forward to avoid asymptomatic screening tests out of fear that something may be positive. That's true to a degree but only if the positive result is of no consequence. For example, an asymptomatic CBC or CMP may reveal anemia that could be colon cancer or transaminitis that could be liver disease. A positive result will send you down the road of more tests. Is this only a bad thing because the frequency of serious pathology (that would be caught by more routine asymptomatic tests) isn't high enough to save the system money by catching things early? Vs. catching it late.

I find that this mentality keeps spreading around too. Don't order tests because you won't know what to do with the result. A nice example is the d dimer. Better not order it in the case of chest pain because then you'll have to do a CTA. God forbit you catch that PE. Don't order an EKG in case in case it's abnormal and leads to an echo. I mean there are a ton of daily examples in every specialty. I've had arguments made against screening for abnormal lipids in young people. Like is it such a bad thing to prevent plaque build up when you're 25 rather than 50 and already had an nstemi ?

And then you end up with cases like: Med Mal Case: Hospitalist, Ischemic Leg | Student Doctor Network

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[VA Hopeful Dr]

Its an added cost with no/little added benefit. I mean, why not get a colonoscopy every year starting at 35?

Its why the head to toe yearly physical is falling out of favor. Turns out doing one doesn't catch problems earlier enough to actual matter assuming you're getting all the scheduled screenings done.

If you have someone who is on no hepatotoxic meds, doesn't do any drugs, doesn't drink, has no significant medical history, and no concerning symptoms then catching a transaminitis that's clinically relevant is blindingly unlikely.

 

[AMEHigh]

Its an added cost with no/little added benefit. I mean, why not get a colonoscopy every year starting at 35?

Its why the head to toe yearly physical is falling out of favor. Turns out doing one doesn't catch problems earlier enough to actual matter assuming you're getting all the scheduled screenings done.

If you have someone who is on no hepatotoxic meds, doesn't do any drugs, doesn't drink, has no significant medical history, and no concerning symptoms then catching a transaminitis that's clinically relevant is blindingly unlikely.

Yeah this.
I’m on another message board that’s not medicine related.
One day people (mostly Americans) were chiming in about all the yearly routine appointments they do like pcp check up, derm, different gyn, etc. The Canadians chimed in and were like what? All that sounds unnecessary, we don’t do any of that.

I certainly think the health care system needs to change to a more equitable one so that the person that’s seen blood in their stool for a year can get a colonoscopy even if they don’t make 6 figures, but I think we need to actually spend less in healthcare and fancy work ups. We know it doesn’t change outcomes.

Overall our health in this country will improve if less people are in poverty and jail, there were things like paid maternity leave, good schools, etc. Spending money on unnecessary work ups won’t change our overall health trajectory.

 

[InternistDO]

From an individual patient care and liability standpoint - it makes more sense to order more tests (in general principle). But we have this notion being put forward to avoid asymptomatic screening tests out of fear that something may be positive. That's true to a degree but only if the positive result is of no consequence. For example, an asymptomatic CBC or CMP may reveal anemia that could be colon cancer or transaminitis that could be liver disease. A positive result will send you down the road of more tests. Is this only a bad thing because the frequency of serious pathology (that would be caught by more routine asymptomatic tests) isn't high enough to save the system money by catching things early? Vs. catching it late.

I find that this mentality keeps spreading around too. Don't order tests because you won't know what to do with the result. A nice example is the d dimer. Better not order it in the case of chest pain because then you'll have to do a CTA. God forbit you catch that PE. Don't order an EKG in case in case it's abnormal and leads to an echo. I mean there are a ton of daily examples in every specialty. I've had arguments made against screening for abnormal lipids in young people. Like is it such a bad thing to prevent plaque build up when you're 25 rather than 50 and already had an nstemi ?

And then you end up with cases like: Med Mal Case: Hospitalist, Ischemic Leg | Student Doctor Network

In addition to what others have said about how increasingly expensive it is to screen low risk people for conditions, many diagnostic and therapeutic workups have very real risks that we often ignore. The problem is not when you catch a giant saddle PE (though with a low Wells score, I imagine this is a one in a million diagnosis), it's when you catch the subsegmental PE in someone who probably had MSK pain, and then you anticoagulate them "to be safe" even though there's really no evidence for that either, and then they have a major bleeding event from the NOAC, or when you injure someone's colon from scoping everyone with an anemia.

I'm still in residency and I've already seen catastrophic strokes as a result of routine PCI, and if you work up a moderate risk factor person with an 'abnormal' EKG it's pretty likely they may end up in the cath lab too.

 

[Keona]

I order more labs than I did during residency in my elderly patients and I’ve caught several cancers early from it. Now I will say we have an in-house lab and it is pretty cheap for me to do labs through it. (One of my Amish patients told me a bmp is $100 cheaper with us than the other doctor’s office she used that didn’t have an in-house lab). My healthy young patients I get labs on every few years so we have baselines to compare. I very strangely helped a patient get diagnosed with a very Renal cell cancer from slightly abnormal gfr and me and him both having a weird feeling about it.

 

[MedicineZ0Z]

Its an added cost with no/little added benefit. I mean, why not get a colonoscopy every year starting at 35?

Its why the head to toe yearly physical is falling out of favor. Turns out doing one doesn't catch problems earlier enough to actual matter assuming you're getting all the scheduled screenings done.

If you have someone who is on no hepatotoxic meds, doesn't do any drugs, doesn't drink, has no significant medical history, and no concerning symptoms then catching a transaminitis that's clinically relevant is blindingly unlikely.

A colonoscopy is invasive. I've caught a couple asymptomatic zebra causes of transaminitis with casual labs along with endless cases of fatty liver. Caught very abnormal lipids in skinny young males and females without family history. Asymptomatic and significant anemia. etc etc. If you go looking for things, you'll find them. Many of which will be insignificant. But anyway this is more of a broad question and point rather than simply asymptomatic outpatient cbc/cmps lol.

There are also many conditions that were previously thought to be rare but are now viewed as being heavily underdiagnosed.

In addition to what others have said about how increasingly expensive it is to screen low risk people for conditions, many diagnostic and therapeutic workups have very real risks that we often ignore. The problem is not when you catch a giant saddle PE (though with a low Wells score, I imagine this is a one in a million diagnosis), it's when you catch the subsegmental PE in someone who probably had MSK pain, and then you anticoagulate them "to be safe" even though there's really no evidence for that either, and then they have a major bleeding event from the NOAC, or when you injure someone's colon from scoping everyone with an anemia.

I'm still in residency and I've already seen catastrophic strokes as a result of routine PCI, and if you work up a moderate risk factor person with an 'abnormal' EKG it's pretty likely they may end up in the cath lab too.

I agree with you in principle 100%. The problem is you'll miss something, and they will sue you and they will win. Send home a low risk PE without a workup, they die from a PE. Then you get sued and lose (this has happened many times as you'd know even better). It's tough to convince a jury otherwise.

 

[anonperson]

From an individual patient care and liability standpoint - it makes more sense to order more tests (in general principle). But we have this notion being put forward to avoid asymptomatic screening tests out of fear that something may be positive. That's true to a degree but only if the positive result is of no consequence. For example, an asymptomatic CBC or CMP may reveal anemia that could be colon cancer or transaminitis that could be liver disease. A positive result will send you down the road of more tests. Is this only a bad thing because the frequency of serious pathology (that would be caught by more routine asymptomatic tests) isn't high enough to save the system money by catching things early? Vs. catching it late.

I find that this mentality keeps spreading around too. Don't order tests because you won't know what to do with the result. A nice example is the d dimer. Better not order it in the case of chest pain because then you'll have to do a CTA. God forbit you catch that PE. Don't order an EKG in case in case it's abnormal and leads to an echo. I mean there are a ton of daily examples in every specialty. I've had arguments made against screening for abnormal lipids in young people. Like is it such a bad thing to prevent plaque build up when you're 25 rather than 50 and already had an nstemi ?

And then you end up with cases like: Med Mal Case: Hospitalist, Ischemic Leg | Student Doctor Network

Choosing wisely is a stupid concept in the current malpractice environment. Saving money for the "system" is a waste of time and energy.

In our current medical environment, no bad outcomes are tolerated.

God forbid you don't order a test or study, then you will really leave yourself vulnerable to an angry jury and some hired gun expert witness who will bury you.

"Ladies and gentlemen of the jury, poor demented Grandma Jones died because Dr. XX didn't order the appropriate tests so they could save the system money."

Until the current legal environment changes, I will always choose more testing.

 

[MedicineZ0Z]

Choosing wisely is a stupid concept in the current malpractice environment. Saving money for the "system" is a waste of time and energy.

In our current medical environment, no bad outcomes are tolerated.

God forbid you don't order a test or study, then you will really leave yourself vulnerable to an angry jury and some hired gun expert witness who will bury you.

"Ladies and gentlemen of the jury, poor demented Grandma Jones died because Dr. XX didn't order the appropriate tests so they could save the system money."

Until the current legal environment changes, I will always choose more testing.

Exactly. You will get 0 credit for saving the system money. And the system has 0 incentive to come up with test guidelines that protect doctors from liability. It's different pockets of money.
You can do an excellent job in 98% of cases, be the most cost effective doctor ever and still get destroyed in a lawsuit due to something that could have been easily caught (and fully prevented) with more tests.

 

[VA Hopeful Dr]

A colonoscopy is invasive. I've caught a couple asymptomatic zebra causes of transaminitis with casual labs along with endless cases of fatty liver. Caught very abnormal lipids in skinny young males and females without family history. Asymptomatic and significant anemia. etc etc. If you go looking for things, you'll find them. Many of which will be insignificant. But anyway this is more of a broad question and point rather than simply asymptomatic outpatient cbc/cmps lol.

There are also many conditions that were previously thought to be rare but are now viewed as being heavily underdiagnosed.

I agree with you in principle 100%. The problem is you'll miss something, and they will sue you and they will win. Send home a low risk PE without a workup, they die from a PE. Then you get sued and lose (this has happened many times as you'd know even better). It's tough to convince a jury otherwise.

I agree that if you go looking for things, you will find them.

The question becomes: does finding them a little earlier change outcomes? The answer is, increasingly, no.

 

[deleted87716]

There's more to Choosing Wisely than "order fewer tests." The recommendations of Choosing Wisely are very specific (see link below). They aren't recommending that you not order any tests that are indicated and appropriate. They're recommending against ordering specific tests that typically are not indicated and are inappropriate. And, as mentioned previously, it's not just about saving money, but also about preventing unnecessary harm (especially in the case of routine PSA testing).

Link: American Academy of Family Physicians | Choosing Wisely

 

[simpler2]

Diagnostic testing is a tool in the provider's belt for evaluating a medical complaint or for performing evidence based primary and secondary preventive screening. I note quite a few replies in this thread that seem to imply misunderstanding of this basic principle (Phrases such as "it couldn't hurt" or "I've caught several _ by doing test _"). If there is no clinical or evidence based reason for performing a test, I would argue it shouldn't be done.
Also, "catching" a malignancy or severe medical problem early in its process does not automatically = you've done something good or changed the course of an illness, especially if you were utiliziling diagnostic testing in a non-clinical way.

 

[turkeyjerky]

There's more to Choosing Wisely than "order fewer tests." The recommendations of Choosing Wisely are very specific (see link below). They aren't recommending that you not order any tests that are indicated and appropriate. They're recommending against ordering specific tests that typically are not indicated and are inappropriate. And, as mentioned previously, it's not just about saving money, but also about preventing unnecessary harm (especially in the case of routine PSA testing).

Link: American Academy of Family Physicians | Choosing Wisely

This, exactly.

I'm very puzzled about the criticism of Choosing Wisely. The recommendations made are are the low-hanging fruit, really none are controversial.

 

[MedicineZ0Z]

I agree that if you go looking for things, you will find them.

The question becomes: does finding them a little earlier change outcomes? The answer is, increasingly, no.

Probably not, agree. But you do save angry patients at that. "I've seen my doctor for 6 years for check ups and he missed it"

 

[VA Hopeful Dr]

Probably not, agree. But you do save angry patients at that. "I've seen my doctor for 6 years for check ups and he missed it"

You'll also save angry patients if you just refill their chronic narcotics and benzos. "My other doctor always did it".

I rarely regret making a patient angry by practicing good medicine.

 

[MedicineZ0Z]

You'll also save angry patients if you just refill their chronic narcotics and benzos. "My other doctor always did it".

I rarely regret making a patient angry by practicing good medicine.

Apples and oranges. Some patient requests are harmful. Some are harmless. As AI and midlevels progress further, customer service and excellent patient reviews will become more and more important. So obviously we stop any and all harmful requests on the spot. But if an asymptomatic patient wants their thyroid or kidneys checked, who cares?

 

[VA Hopeful Dr]

Apples and oranges. Some patient requests are harmful. Some are harmless. As AI and midlevels progress further, customer service and excellent patient reviews will become more and more important. So obviously we stop any and all harmful requests on the spot. But if an asymptomatic patient wants their thyroid or kidneys checked, who cares?

Very few are actually harmless.

 

[MedicineZ0Z]

Very few are actually harmless.

Such as

 

[VA Hopeful Dr]

Such as

Name a test

 

[MedicineZ0Z]

Name a test

I already did. In almost every case, if it's abnormal - you probably want to know about it and address it. A super healthy 60 year old with a new prostate cancer and slowly up creeping PSA will likely benefit from early treatment. Very mildly symptomatic hemochromatosis as found by transaminitis will benefit from earlier treatment too. There are lots of examples of this.

Also, I think the main point was liability. You don't win an award for not ordering that a d-dimer. But you will lose the lawsuit for missing the PE.

 

[VA Hopeful Dr]

I already did. In almost every case, if it's abnormal - you probably want to know about it and address it. A super healthy 60 year old with a new prostate cancer and slowly up creeping PSA will likely benefit from early treatment. Very mildly symptomatic hemochromatosis as found by transaminitis will benefit from earlier treatment too. There are lots of examples of this.

Also, I think the main point was liability. You don't win an award for not ordering that a d-dimer. But you will lose the lawsuit for missing the PE.

So you order a d-dimer on every patient every time you see one? Otherwise you might miss a PE.

Let's say you order a BMP on an asymptomatic patient. You end up with an elevated creatinine. You get an ultrasound, 24h urine, SPEP/UPEP, vitamin d, magnesium. All of those are normal. The nephrologist you send the patient to gets a biopsy to rule out anything else that might be going on. Patient ends up with post-biopsy hemorrhage (11% risk) needing a blood transfusion (1.6%). Turns out its the day after the healthy 45 year old ate a 24oz well done Porterhouse by himself.

Let's say you get a CBC on a young female patient who has an IUD so no menses in over 2 years. Iron is borderline low so you send for EGD/colonoscopy. During the colonoscopy there is a perforation (0.5% risk) leading to a hemicoloectomy. Turns out the patient is a strict vegan and really just wasn't getting enough iron from her diet.

 

[InternistDO]

I don't believe there's any evidence that physicians who over test are any less likely to be sued. The number one predictor of being in a lawsuit is being a dingus.

Practicing to appease patients and lawyers might make the day go by more easily but I don't think one could make the argument that it's good medicine.

 

[MedicineZ0Z]

So you order a d-dimer on every patient every time you see one? Otherwise you might miss a PE.

Or you get it when it's indicated? We get borderline cases all the time where some will use clinical judgement to not do it and some will.
How about nonspecific radiating shoulder pain to the back with no solid MSK cause, for a female on OCPs who is borderline tachycardic?

Let's say you order a BMP on an asymptomatic patient. You end up with an elevated creatinine. You get an ultrasound, 24h urine, SPEP/UPEP, vitamin d, magnesium. All of those are normal. The nephrologist you send the patient to gets a biopsy to rule out anything else that might be going on. Patient ends up with post-biopsy hemorrhage (11% risk) needing a blood transfusion (1.6%). Turns out its the day after the healthy 45 year old ate a 24oz well done Porterhouse by himself.

I don't understand that example. You repeat an elevated creatinine first, and you can also get a cystatin C to verify there is true renal disease. If it's persistent, I would do a far more comprehensive lab workup (rule out all nephrotic/nephritic/vasculitis syndromes) before referring for a biopsy. That example doesn't stand.

Let's say you get a CBC on a young female patient who has an IUD so no menses in over 2 years. Iron is borderline low so you send for EGD/colonoscopy. During the colonoscopy there is a perforation (0.5% risk) leading to a hemicoloectomy. Turns out the patient is a strict vegan and really just wasn't getting enough iron from her diet.

Would not send for scopes based off that.

Most lab abnormalities can be addressed properly before you get to the point of risky intervention.

 

[AMEHigh]

I already did. In almost every case, if it's abnormal - you probably want to know about it and address it. A super healthy 60 year old with a new prostate cancer and slowly up creeping PSA will likely benefit from early treatment. Very mildly symptomatic hemochromatosis as found by transaminitis will benefit from earlier treatment too. There are lots of examples of this.

Also, I think the main point was liability. You don't win an award for not ordering that a d-dimer. But you will lose the lawsuit for missing the PE.

Huh?
Isn’t that exactly why they changed the Psa testing to "shared decision making" because people were getting over treated and it was causing harm? I’m not a man but i certainly wouldn’t want to go through prostate cancer treatment and be impotent and have incontinence for 20 years if I was going to die of something else anyway.

So no "early treatment" isn’t always the best answer.

There are plenty of things that it’s been found that early detection doesn’t always lead to decreasing morbidity or mortality. Didn’t you learn that in med school and residency?

That’s also exactly why they changed the Pap smear guidelines. Women were getting over treated with LEEPs and cones and causing cervical stenosis, causing difficulty with fertility and other issues and not improving cervical cancer outcomes.

So are you just saying you don’t follow evidence based medicine?

 

[MedicineZ0Z]

Huh?
Isn’t that exactly why they changed the Psa testing to "shared decision making" because people were getting over treated and it was causing harm? I’m not a man but i certainly wouldn’t want to go through prostate cancer treatment and be impotent and have incontinence for 20 years if I was going to die of something else anyway.

Go tell this to the families of people who had their father/husband die of prostate cancer and were otherwise healthy.
Shared decision making is one aspect. But to tell a healthy person (in that shared decision making convo) that they'll likely die of something else is not entirely true nor evidence based. The patient on 0-1 meds is not in the same category as the uncontrolled diabetic CKDIII CHF patient.

So no "early treatment" isn’t always the best answer.

There are plenty of things that it’s been found that early detection doesn’t always lead to decreasing morbidity or mortality. Didn’t you learn that in med school and residency?

That’s also exactly why they changed the Pap smear guidelines. Women were getting over treated with LEEPs and cones and causing cervical stenosis, causing difficulty with fertility and other issues and not improving cervical cancer outcomes.

So are you just saying you don’t follow evidence based medicine?

I think the conversation got carried the wrong direction. I was talking about doing the necessary tests to avoid getting sued given that being cost effective won't spare the jury.

 

[AMEHigh]

Go tell this to the families of people who had their father/husband die of prostate cancer and were otherwise healthy.
Shared decision making is one aspect. But to tell a healthy person (in that shared decision making convo) that they'll likely die of something else is not entirely true nor evidence based. The patient on 0-1 meds is not in the same category as the uncontrolled diabetic CKDIII CHF patient.


I think the conversation got carried the wrong direction. I was talking about doing the necessary tests to avoid getting sued given that being cost effective won't spare the jury.

It seems as though your definition of necessary testing isn’t based on evidence though. So are you ordering every test under the sun for your patients?

Sure it sucks to get sued, but in general if you’re following guidelines and have proper documentation then one should be confident in the care they’re providing.

There’s tons of evidence as to why yearly Pap smears for cervical cancer, ca-125 for ovarian cancer, psa for prostate cancer can actually do more harm than good.

If you do Pap smears every year on a patient, then do a colpo and then a LEEP and then that person has difficulty with having a child a year later and decides to sue you, how is that any better than just following the guidelines?

Since you seem to be mostly concerned about getting sued, the risk for getting sued can go both ways...under work up or over work up. So in order to avoid that just use evidence based work up!

 

[MedicineZ0Z]

It seems as though your definition of necessary testing isn’t based on evidence though. So are you ordering every test under the sun for your patients?

Not at all. But this conversation is also geared towards hospital medicine. Thoroughly working up a chief complaint doesn't always have a set guideline (often does not) and what one doctor considers thorough is often drastically different from another doctor.

Sure it sucks to get sued, but in general if you’re following guidelines and have proper documentation then one should be confident in the care they’re providing.

Agree, though documentation doesn't actually save you contrary to what many doctors think.

There’s tons of evidence as to why yearly Pap smears for cervical cancer, ca-125 for ovarian cancer, psa for prostate cancer can actually do more harm than good.

I don't know any docs who do annual paps and never met one who does ca-125 for screening. I would think it's nuts. Though I absolutely do annual PSAs on all healthy males once they hit the age. Bread and butter comorbid patients get the shared-decision convo and truly sick ones don't get a screening PSA.

If you do Pap smears every year on a patient, then do a colpo and then a LEEP and then that person has difficulty with having a child a year later and decides to sue you, how is that any better than just following the guidelines

Since you seem to be mostly concerned about getting sued, the risk for getting sued can go both ways...under work up or over work up. So in order to avoid that just use evidence based work up!

Most chief complaints don't have set guidelines on working them up. You can decide to keep playing with meds with your refractory hypertension or... evaluate for hyperaldosteronism. There isn't a universal guideline.

 

[AMEHigh]

Not at all. But this conversation is also geared towards hospital medicine. Thoroughly working up a chief complaint doesn't always have a set guideline (often does not) and what one doctor considers thorough is often drastically different from another doctor.

Agree, though documentation doesn't actually save you contrary to what many doctors think.

I don't know any docs who do annual paps and never met one who does ca-125 for screening. I would think it's nuts. Though I absolutely do annual PSAs on all healthy males once they hit the age. Bread and butter comorbid patients get the shared-decision convo and truly sick ones don't get a screening PSA.


Most chief complaints don't have set guidelines on working them up. You can decide to keep playing with meds with your refractory hypertension or... evaluate for hyperaldosteronism. There isn't a universal guideline.

Huh? Your first post said ". But we have this notion being put forward to avoid asymptomatic screening tests out of fear that something may be positive." And then talked about lipid screening in young patients. But now you’re saying you’re talking about hospital medicine and chief complaints?

Yes it seems this conversation has jumped the shark because the OP was about asymptomatic screenings, so that’s what I was discussing.

I no longer do hospital medicine so carry on!

 

[hallowmann]

I think part of the problem is the way the OP presented the argument. The Choosing Wisely campaign is actually very practical and addresses reasonable limitations to our screening methods and ability to intervene. It also emphasizes shared decision making, individualized care, and patient education, all things I can get behind.

That said, there are situations I've encountered that are concerning that I feel fall into that "art of medicine" realm. I too have seen tons of patients where for whatever reason that day I decided on a CMP or even BMP and found something that needed further workup.

A kid in his late 20s with a GFR <80 with no explanation got lots of lab testing, but when it stayed stable with no active signs of acute disease, no crazy protein in urine, etc., I'm not sending the kid to Nephro for a biopsy unless I'm seeing progression. For the 32 yo non-drinker, non- supplement/medication taker with a BMI of 28, who came in to establish with a PCP after 5 years without an annual, with no symptoms (other than feeling tired with a newborn), and no notable family history, my randomly getting a CMP that day because he's never had one here found LFTs >8x ULN. That kid went to Hepatology and has PSC with F3 fibrosis on elastography that's biopsy confirmed. It's a zebra, but now he's on treatment and LFTs have come down and I'm hoping it'll mean delay in time to transplant.

For the pt with anemia, I'm not sending to GI for a scope unless I at least do a guaiac and find blood, and I hope the GI (most likely PA/NP) won't sign the 20-something Vegan up for a colonoscopy just for anemia without that even if I sent them without it. That seems obvious to me.

I believe there is room and a balance that can be struck, but in my opinion it requires actually seeing and getting to know people and their priorities, and using your doctor brain rather than just an algorithm.

rant
That's honestly why I hate the push against regular physicals.

Sure, I'm not going to care if a 20 year old doesn't see me for a couple years, but I'm not going to tell them they shouldn't and miss depression, anxiety, or substance use that would be worth intervening. Also, the assumption that you're within guidelines with those people feels ridiculous. How do you even do that with people that you don't see every 1-2 yrs? If I don't see a PCP for 4 years, what are the chances I'm coming back at 5 yrs or even 7 yrs for that lipid panel, even if I gained 30 lbs since the last time? Will I even find one with new patient openings in the next 3 mos? I think it's stupid to push this narrative that there's no need for physicals, because what lay people come away with is that they don't need a PCP and that's wrought with problems because ultimately they won't get preventive care.
/rant

 

[VA Hopeful Dr]

Or you get it when it's indicated? We get borderline cases all the time where some will use clinical judgement to not do it and some will.
How about nonspecific radiating shoulder pain to the back with no solid MSK cause, for a female on OCPs who is borderline tachycardic?

That's not what you said in the OP:

From an individual patient care and liability standpoint - it makes more sense to order more tests (in general principle). But we have this notion being put forward to avoid asymptomatic screening tests out of fear that something may be positive. That's true to a degree but only if the positive result is of no consequence. For example, an asymptomatic CBC or CMP may reveal anemia that could be colon cancer or transaminitis that could be liver disease. A positive result will send you down the road of more tests. Is this only a bad thing because the frequency of serious pathology (that would be caught by more routine asymptomatic tests) isn't high enough to save the system money by catching things early? Vs. catching it late.

 

[VA Hopeful Dr]

I think part of the problem is the way the OP presented the argument. The Choosing Wisely campaign is actually very practical and addresses reasonable limitations to our screening methods and ability to intervene. It also emphasizes shared decision making, individualized care, and patient education, all things I can get behind.

That said, there are situations I've encountered that are concerning that I feel fall into that "art of medicine" realm. I too have seen tons of patients where for whatever reason that day I decided on a CMP or even BMP and found something that needed further workup.

A kid in his late 20s with a GFR <80 with no explanation got lots of lab testing, but when it stayed stable with no active signs of acute disease, no crazy protein in urine, etc., I'm not sending the kid to Nephro for a biopsy unless I'm seeing progression. For the 32 yo non-drinker, non- supplement/medication taker with a BMI of 28, who came in to establish with a PCP after 5 years without an annual, with no symptoms (other than feeling tired with a newborn), and no notable family history, my randomly getting a CMP that day because he's never had one here found LFTs >8x ULN. That kid went to Hepatology and has PSC with F3 fibrosis on elastography that's biopsy confirmed. It's a zebra, but now he's on treatment and LFTs have come down and I'm hoping it'll mean delay in time to transplant.

For the pt with anemia, I'm not sending to GI for a scope unless I at least do a guaiac and find blood, and I hope the GI (most likely PA/NP) won't sign the 20-something Vegan up for a colonoscopy just for anemia without that even if I sent them without it. That seems obvious to me.

I believe there is room and a balance that can be struck, but in my opinion it requires actually seeing and getting to know people and their priorities, and using your doctor brain rather than just an algorithm.

rant
That's honestly why I hate the push against regular physicals.

Sure, I'm not going to care if a 20 year old doesn't see me for a couple years, but I'm not going to tell them they shouldn't and miss depression, anxiety, or substance use that would be worth intervening. Also, the assumption that you're within guidelines with those people feels ridiculous. How do you even do that with people that you don't see every 1-2 yrs? If I don't see a PCP for 4 years, what are the chances I'm coming back at 5 yrs or even 7 yrs for that lipid panel, even if I gained 30 lbs since the last time? Will I even find one with new patient openings in the next 3 mos? I think it's stupid to push this narrative that there's no need for physicals, because what lay people come away with is that they don't need a PCP and that's wrought with problems because ultimately they won't get preventive care.
/rant

I think you might be misinterpreting the anti-physical push. A yearly preventative care visit is still a great idea (hence the AWV), it's the head-to-toe physical exam that's fallen out of favor.

 

[hallowmann]

I think you might be misinterpreting the anti-physical push. A yearly preventative care visit is still a great idea (hence the AWV), it's the head-to-toe physical exam that's fallen out of favor.

I see articles all the time from health policy people or politician-physicians (usually specialists) that advocate getting rid of annual physicals under x age. It's usually the same people that push for NP/PA take over of primary care because "it's easy enough" or "a waste" of physician training.

I guess I don't know what you mean by "head-to-toe" physicals. The physicals I was trained to do incorporate age- related screening, updating pmhx, shx, sochx, fmhx, etc, and I incorporate a discussion about diet, exercise, and informal mood assessment. The exam is usually a quick 2-3 min physical that incorporates all regions. It feels head-to-toe to me.

 

[deleted87716]

Since you seem to be mostly concerned about getting sued, the risk for getting sued can go both ways...under work up or over work up. So in order to avoid that just use evidence based work up!

Yep.

Dangers of Medical Overtreatment - The Sanders Firm

We place a lot of trust in the knowledge and experience of medical professionals in America. It’s easy to believe that tests are the best way to diagnose

thesandersfirm.com

Improving Quality by Doing Less: Overtreatment

The third in a series of AFP editorials that addresses the related issues of over-screening, overdiagnosis, and overtreatment. Overtreatment is an important harm that commonly follows overscreening and overdiagnosis.

www.aafp.org

 

[deleted87716]

I see articles all the time from health policy people or politician-physicians (usually specialists) that advocate getting rid of annual physicals under x age. It's usually the same people that push for NP/PA take over of primary care because "it's easy enough" or "a waste" of physician training.

I guess I don't know what you mean by "head-to-toe" physicals. The physicals I was trained to do incorporate age- related screening, updating pmhx, shx, sochx, fmhx, etc, and I incorporate a discussion about diet, exercise, and informal mood assessment. The exam is usually a quick 2-3 min physical that incorporates all regions. It feels head-to-toe to me.

The "head to toe" part is referring to a complete physical examination, most of which is unnecessary in someone who is apparently healthy without any complaints. This is different from regular health assessments or preventive care visits, which I agree are beneficial. I've tried to get away from the "physical" terminology for this reason.

 

[VA Hopeful Dr]

The "head to toe" part is referring to a complete physical examination, most of which is unnecessary in someone who is apparently healthy without any complaints. This is different from regular health assessments preventive care visits, which I agree are beneficial. I've tried to get away from the "physical" terminology for this reason.

That exactly.

For annual physical visits I do heart/lungs, shine a light in eyes and mouth, cervical lymph nodes, patellar reflexes, UE pulses. And the vast majority of that is doctor theatre for the patient's sake.

 

[hallowmann]

That exactly.

For annual physical visits I do heart/lungs, shine a light in eyes and mouth, cervical lymph nodes, patellar reflexes, UE pulses. And the vast majority of that is doctor theatre for the patient's sake.

I mean, it's not much different than what I do, except I do an abdominal exam, LE pulses and some extremity strength/sensation in my neuro exam. I mean, its shorter for the young people, that I'm not worried about, but I partly do it because it's my routine, fits with my documentation template, and doesn't add more than 1-2 min to the visit. Plus I'm a bone wizard and I think there's value in laying of the hands and what not more for rapport.

 

[VA Hopeful Dr]

I mean, it's not much different than what I do, except I do an abdominal exam, LE pulses and some extremity strength/sensation in my neuro exam. I mean, its shorter for the young people, that I'm not worried about, but I partly do it because it's my routine, fits with my documentation template, and doesn't add more than 1-2 min to the visit. Plus I'm a bone wizard and I think there's value in laying of the hands and what not more for rapport.

Other than heart and lungs, I 100% do the rest of the exam for just that reason.

But that's not the traditional head to toe physical exam of years past. Historically, that included every exam bullet point from this: https://www.aafp.org/fpm/1999/0700/fpm19990700p32-rt1.pdf

 

[VA Hopeful Dr]

I think part of the problem is the way the OP presented the argument. The Choosing Wisely campaign is actually very practical and addresses reasonable limitations to our screening methods and ability to intervene. It also emphasizes shared decision making, individualized care, and patient education, all things I can get behind.

That said, there are situations I've encountered that are concerning that I feel fall into that "art of medicine" realm. I too have seen tons of patients where for whatever reason that day I decided on a CMP or even BMP and found something that needed further workup.

A kid in his late 20s with a GFR <80 with no explanation got lots of lab testing, but when it stayed stable with no active signs of acute disease, no crazy protein in urine, etc., I'm not sending the kid to Nephro for a biopsy unless I'm seeing progression. For the 32 yo non-drinker, non- supplement/medication taker with a BMI of 28, who came in to establish with a PCP after 5 years without an annual, with no symptoms (other than feeling tired with a newborn), and no notable family history, my randomly getting a CMP that day because he's never had one here found LFTs >8x ULN. That kid went to Hepatology and has PSC with F3 fibrosis on elastography that's biopsy confirmed. It's a zebra, but now he's on treatment and LFTs have come down and I'm hoping it'll mean delay in time to transplant.

For the pt with anemia, I'm not sending to GI for a scope unless I at least do a guaiac and find blood, and I hope the GI (most likely PA/NP) won't sign the 20-something Vegan up for a colonoscopy just for anemia without that even if I sent them without it. That seems obvious to me.

I believe there is room and a balance that can be struck, but in my opinion it requires actually seeing and getting to know people and their priorities, and using your doctor brain rather than just an algorithm.

rant
That's honestly why I hate the push against regular physicals.

Sure, I'm not going to care if a 20 year old doesn't see me for a couple years, but I'm not going to tell them they shouldn't and miss depression, anxiety, or substance use that would be worth intervening. Also, the assumption that you're within guidelines with those people feels ridiculous. How do you even do that with people that you don't see every 1-2 yrs? If I don't see a PCP for 4 years, what are the chances I'm coming back at 5 yrs or even 7 yrs for that lipid panel, even if I gained 30 lbs since the last time? Will I even find one with new patient openings in the next 3 mos? I think it's stupid to push this narrative that there's no need for physicals, because what lay people come away with is that they don't need a PCP and that's wrought with problems because ultimately they won't get preventive care.
/rant

Interestingly the GI doctors have been saying for awhile that FOBT is a cancer screening test only and shouldn't be used to evaluate for GIB.

 

[hallowmann]

Other than heart and lungs, I 100% do the rest of the exam for just that reason.

But that's not the traditional head to toe physical exam of years past. Historically, that included every exam bullet point from this: https://www.aafp.org/fpm/1999/0700/fpm19990700p32-rt1.pdf

Yeah that's ridiculous. I've never done that and it would easily add 10-15 min to those visits.

Interestingly the GI doctors have been saying for awhile that FOBT is a cancer screening test only and shouldn't be used to evaluate for GIB.

I mean for a bleed enough to cause anemia, I would expect blood in stool even if it's not grossly apparent provided there isn't some confounder for the test. Maybe the issue is with not having an adequate sample/operator error. At least inpatient here, the GI service also expects a guaiac.

 

[VA Hopeful Dr]

Yeah that's ridiculous. I've never done that and it would easily add 10-15 min to those visits.


I mean for a bleed enough to cause anemia, I would expect blood in stool even if it's not grossly apparent provided there isn't some confounder for the test. Maybe the issue is with not having an adequate sample/operator error. At least inpatient here, the GI service also expects a guaiac.

Hence why yearly physicals used to take an hour.

@Gastrapathy would you mind weighing in on the FOBT for GI bleeds?

 

[AMEHigh]

Hence why yearly physicals used to take an hour.

@Gastrapathy would you mind weighing in on the FOBT for GI bleeds?

Yeah every GI person I’ve talked with who is up to date on the evidence says FOBT is useless and shouldn’t be done.

 

[hallowmann]

Yeah every GI person I’ve talked with who is up to date on the evidence says FOBT is useless and shouldn’t be done.

Are you saying useless in terms of ruling out with a high index of suspicion for GIB? In which case I would agree.

But I was talking about in the example above by @VA Hopeful Dr, "CBC on a young female patient who has an IUD so no menses in over 2 years. Iron is borderline low so you send for EGD/colonoscopy", in that case, index of suspicion for GIB is low and I could see doing a guaiac and if negative, then pursuing other potential causes of anemia first, before jumping to GI consult for scopes.

 

[Gastrapathy]

FOBT obtained for anything other than CRC screening is worse than pointless. It hasn’t been studied and can easily lead to unnecessary testing or worse be falsely reassuring. Rectal for assessment for melena or BRB matters. When I hear a FOBT result in a presentation, I’ll explain to residents that it’s unhelpful (all our ED residents know it by now) but I don’t bother with attendings anymore.

 

[AMEHigh]

Are you saying useless in terms of ruling out with a high index of suspicion for GIB? In which case I would agree.

But I was talking about in the example above by @VA Hopeful Dr, "CBC on a young female patient who has an IUD so no menses in over 2 years. Iron is borderline low so you send for EGD/colonoscopy", in that case, index of suspicion for GIB is low and I could see doing a guaiac and if negative, then pursuing other potential causes of anemia first, before jumping to GI consult for scopes.

No, it's useless in that scenario.
You previously mentioned being sued and this is another example of doing an extra test isn't the thing that's going to save you because guidelines and specialists don't recommend it as it can be falsely positive or negative.

 

[hallowmann]

No, it's useless in that scenario.
You previously mentioned being sued and this is another example of doing an extra test isn't the thing that's going to save you because guidelines and specialists don't recommend it as it can be falsely positive or negative.

When did I mention being sued? I think you mixed me up with the OP. Being sued isn't really a huge driving factor for the decisions I make.

FOBT is useless in the context of ruling out GIB, sure, but there's a clear process that involves it for pts with mild anemia or iron deficiency thats laid out in Up-To-Date.

I'm not sending someone like that pt described for a GI consult and scope until I've done more tests/evaluation including FOBT. If more things point to GIB or if other things are ruled out then I'd send them. If its positive, I would send them for a GI consult first. Or if my index of suspicion was high, I'd already have sent them without the FOBT. Again, its laid out in the UTD article about occult bleeding. (EDIT: Link if you want it - UpToDate)

Serious question: are you guys literally sending every young patient with mild anemia to GI without further evaluation?

 

[VA Hopeful Dr]

When did I mention being sued? I think you mixed me up with the OP. Being sued isn't really a huge driving factor for the decisions I make.

FOBT is useless in the context of ruling out GIB, sure, but there's a clear process that involves it for pts with mild anemia or iron deficiency thats laid out in Up-To-Date.

I'm not sending someone like that pt described for a GI consult and scope until I've done more tests/evaluation including FOBT. If more things point to GIB or if other things are ruled out then I'd send them. If its positive, I would send them for a GI consult first. Or if my index of suspicion was high, I'd already have sent them without the FOBT. Again, its laid out in the UTD article about occult bleeding. (EDIT: Link if you want it - UpToDate)

Serious question: are you guys literally sending every young patient with mild anemia to GI without further evaluation?

Depends what you mean by further evaluation. For me, if I can't find another clear cut cause I do send.

IDA with heavy periods? No GI. S/P gastric bypass? Probably no GI. Bad CKD? If I can prove its a stable anemia, then no GI. But I'd guess I send more people with IDA to GI than not.

UpToDate is fine, unless the specialists in that area have a different approach in which case I defer to them.

 

[AMEHigh]

When did I mention being sued? I think you mixed me up with the OP. Being sued isn't really a huge driving factor for the decisions I make.

FOBT is useless in the context of ruling out GIB, sure, but there's a clear process that involves it for pts with mild anemia or iron deficiency thats laid out in Up-To-Date.

I'm not sending someone like that pt described for a GI consult and scope until I've done more tests/evaluation including FOBT. If more things point to GIB or if other things are ruled out then I'd send them. If its positive, I would send them for a GI consult first. Or if my index of suspicion was high, I'd already have sent them without the FOBT. Again, its laid out in the UTD article about occult bleeding. (EDIT: Link if you want it - UpToDate)

Serious question: are you guys literally sending every young patient with mild anemia to GI without further evaluation?

Oops yes confused you with someone else! Sorry about that.
No, I always work up anemia.
I actually don’t check CBC unless there’s an indication to do so, but yes if I do find it I do anemia work up first, never done a FOBT. Rarely have to send to GI.

 

[hallowmann]

Depends what you mean by further evaluation. For me, if I can't find another clear cut cause I do send.

IDA with heavy periods? No GI. S/P gastric bypass? Probably no GI. Bad CKD? If I can prove its a stable anemia, then no GI. But I'd guess I send more people with IDA to GI than not.

UpToDate is fine, unless the specialists in that area have a different approach in which case I defer to them.

Oops yes confused you with someone else! Sorry about that.
No, I always work up anemia.
I actually don’t check CBC unless there’s an indication to do so, but yes if I do find it I do anemia work up first, never done a FOBT. Rarely have to send to GI.

I will work these people up similarly, if I don't find a cause and it doesn't resolve I would send them as well. I generally don't get a CBC/Hgb unless, like you all said, there's an indication (obviously excluding pregnant women and kids, they get screened), but if someone's in their 40s or above I probably will. Honestly the only people I really end up sending to GI are people that again either have a story of overt blood, I see it on DRE, positive guaiac or I don't find a more likely cause of the IDA.

Maybe, I shouldn't be doing guaiac and I'm sending more people to GI because of it, but its always been part of my DRE routine (grab a card, do the DRE, wipe and develop), assuming the DRE is not for something else, e.g. prostate. I see a lot of people that get lost to follow-up, so if its positive they get the consult. Its rarely positive though (again the people I'm checking aren't the ones where I have a high suspicion of GIB or who I'm sending to GI anyway and I'm not doing it on a lot of people). Most of those people with positives end up with ulcers/chronic GERD/esophagitis more than anything else.

 

[Bacchus]

That exactly.

For annual physical visits I do heart/lungs, shine a light in eyes and mouth, cervical lymph nodes, patellar reflexes, UE pulses. And the vast majority of that is doctor theatre for the patient's sake.

I’m going to be the PITA. Also I wouldn’t expect you to list everything you’re doing during your exam for us. But please palpate the thyroid. It’s completely anecdotal/firsthand bias but it saved me a world of hurt. Most patients don’t advance past ultrasound to biopsy but even those who do, tissue genetic testing often prevents surgery if not indicated. You won’t find a ton of nodules but even with “Choosing Wisely” serial ultrasounds isn’t a huge waste of resources or dollars in my opinion. I’m hypervigilant over thyroid exam/workup but follow the ATA guidelines. It’s an added perk our radiologists include the ATA biopsy guidelines on their ultrasound reports.

 

[Bacchus]

Depends what you mean by further evaluation. For me, if I can't find another clear cut cause I do send.

IDA with heavy periods? No GI. S/P gastric bypass? Probably no GI. Bad CKD? If I can prove its a stable anemia, then no GI. But I'd guess I send more people with IDA to GI than not.

UpToDate is fine, unless the specialists in that area have a different approach in which case I defer to them.

Are you routinely following CBC with TIBC panels and ferritin? Sorry if you mentioned it elsewhere. I’ve had a lot of patients (in the anemia workup pathway) who don’t tolerate PO iron or have abysmal ferritin stores despite repletement and they get sent to Heme for infusions and feel better. Thoughts? No animosity, just curiosity.

 

[VA Hopeful Dr]

Are you routinely following CBC with TIBC panels and ferritin? Sorry if you mentioned it elsewhere. I’ve had a lot of patients (in the anemia workup pathway) who don’t tolerate PO iron or have abysmal ferritin stores despite repletement and they get sent to Heme for infusions and feel better. Thoughts? No animosity, just curiosity.

Yes I do, and I see that a couple times a year as well.