The new Choosing Wisely campaign is centered on lists of “unnecessary” medical tests and procedures. The hope is that these lists will reduce waste in the health care system. I wondered what “unnecessary” meant so I interviewed Daniel Wolfson, who is Executive Vice President and Chief Operating Officer of the American Board of Internal Medicine, located in Philadelphia.
At the heart of my question was: why these procedures and not others? Each list has five items. How were they chosen? Here is how the five items on the American College of Physicians’ list were selected:
The American College of Physicians (ACP) formed a workgroup of eleven experienced internal medicine physicians with specific skills in the assessment of evidence. . . . The group collaboratively identified and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. The results were further reviewed and narrowed by clinically active ACP staff physicians before being placed for review into a randomly selected internal medicine research panel. Representing 1 percent of ACP members, the panel selected five scenarios that represented the greatest potential for overuse or misuse of a diagnostic test leading to low value care.
I said this sounded like a popularity contest. Mr. Wolfson said, no, the recommendations are based on evidence. “Do you know what a randomized trial is?” he asked. What evidence? I said. It’s not on your website.
Yes, it’s there, said Mr. Wolfson. He pointed me to the “sources” at the end of the ACP list. Here is one of those sources:
2011 USPSTF screening for coronary heart disease with electrocardiography (draft) guideline; 2011 AAFP recommendations for preventive services guideline; 2010 ACCF/AHA assessment of cardiovascular risk in asymptomatic adults guideline.
This is evidence? I said. It’s very vague. At this point Mr. Wolfson ended the interview.
So I continue to think it is a popularity contest. Who knows how the doctors on that “randomly selected internal medicine research panel” made their decisions.
I think the Choosing Wisely campaign is worthwhile, in spite of Mr. Wolfson’s implausible claims (he also said the doctors who created these lists were “courageous”). Here’s what I would say: The items on these lists are things that many doctors in that specialty think are done too often. The lists are like a free second opinion.
I agree that the “evidence” is vague, but at the same time, I just googled “2011 USPSTF screening for coronary heart disease with electrocardiography” and found the USPSTF’s 2004 guidelines (which do not appear to have changed in regards to screening exercise ECG testing). That page is here: https://www.uspreventiveservicestaskforce.org/uspstf/uspsacad.htm
And here is the accompanying “summary of evidence”, which looks pretty thorough (though I admit I’ve looked at it for all of 15 seconds)
https://www.uspreventiveservicestaskforce.org/3rduspstf/chd/chdsum1.htm
Seth: Thanks, that’s helpful. I’ve looked at it for more than 15 seconds. Here’s part of what it says: “when the risk for coronary heart disease events is low, most positive findings will be false and may result in unnecessary further testing or worry. The risk level at which the benefits of additional prognostic information outweigh the harms of false-positive results is unclear and requires further study.” I think that it is true for a large fraction of medical tests that “most positive findings will be false and may result in unnecessary further testing or worry”. So why pick these five?
“Do you know what a randomized trial is?” I read that and now I am wiping tea off of my keyboard.