knowing when NOT to do something

Medical costs are out of control. Yet, outcomes are not improving. Why?

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Greater minds than mine have grappled with that question, and it serves as the foundation for our ongoing debate about whether, why and how to reform healthcare. Do we limit the tests and procedures that doctors are allowed to order or perform? Do we limit what services or medications patients are allowed to receive? Or do we do something much smarter, and help to guide patients, their families and physicians in having a conversation about how useful certain tests or procedures might be?

The latter approach is the focus of a campaign that is growing traction around the nation.

The campaign is called Choosing Wisely, and was developed by a collaboration of many medical societies and the American Board of Internal Medicine Foundation.Each of approximately 80 specialty societies was asked to make a list of the top 5 procedures or tests for which there is no evidence to support the use in routine patient care. The American Academy of Pediatrics released its list last week.

I am in agreement with the Top Five, as shown below

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I am not, however, in agreement with the wording.

Some of these sound as if the AAP is saying that "Physicians and Patients should question the statements that are made here."

Let's look at number 5.

I see many infnants and children receiving CT scans of the abdomen in evaluation of their abdominal pain, generally in an emergency department. Some children with chronic abdominal pain might receive 3 or 4 CT scans in a single year. So the statement that "CT scans are not necessary in the routine evaluation of abdominal pain" is a TRUE statement. It is NOT this statement that needs to be questioned (five references are provided in support of this statement which you can access here). 
Rather, the whole situation needs to be discussed. The pros and cons clearly delineated. There is a REAL risk of increased radiation exposure and lifetime increased risk of developing cancer with CT scans. So they should ONLY be used when there is a high chance of finding an urgent or emergent issue that needs immediate intervention. 

Despite our reliance on technology and data, the majority of patients can have their abdominal pain diagnosed with a thorough history and a complete physical exam. There will be times when a CT is necessary. When that time arises, it is important to know that the particular hospital uses PEDIATRIC PROTOCOLS for radation strength, so that a 5 year old is not getting the same dose of radiation as a typical 50-year-old. 

What do you think about these "Top Five"? Do you think if all organizations' "top five" lists are followed, that we could have better health care at lower cost? That is the intent of this campaign. Will it happen?

Will you discuss these with your doctor the next time you are told your child "has a viral infection" but he or she wants to prescribe an antibiotic any way?

I would love to hear your thoughts in the comments section below

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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