A new campaign hopes to persuade doctors from carrying out unnecessary – or even harmful – procedures and tests. Here are some you should watch for
A campaign, Choosing Wisely, to help doctors to cause less harm is gaining momentum across the world. It began in the US two years ago, with the American Board of Internal Medicine (ABIM) helping specialists to compile lists of unnecessary or harmful medical interventions in their field. In the UK, the National Institute for Health and Care Excellence (Nice) drew up its own list of “do not do” guidance for doctors. But old habits die hard and doctors still routinely prescribe tests, drugs and procedures that are useless to you. Here are five do-not-dos that doctors continue to flout.
1. Do not scan for lower back pain
Lower back pain usually gets better within a month. People who have x-rays, CT or MRI scans are more likely to end up having an operation than those who don’t have the tests. But, on average, both groups recover in the same time period. Around 99% of people with lower back pain who go to their GP have a mechanical problem that will usually sort itself out. But how do you know whether you’re part of the unlucky 1%, with a serious underlying condition that needs urgent attention? Doctors are trained to identify the danger signs, or red flags, which should trigger intervention. These include a previous cancer diagnosis, osteoporosis, or a recent bad fall. You can find the red flags on the NHS Choices website.
Bottom line: Don’t have a scan or x-ray for mechanical lower-back pain in the first six weeks.
2. Do not prescribe cough medicines to kids
Most coughs and colds in kids are caused by viruses – symptoms typically last for a few days, then get better. Paracetamol or ibuprofen are OK to give for a high fever. Antibiotics don’t work against viruses – and remedies for tickly or dry coughs, runny or blocked noses and sore throats shouldn’t be prescribed either, says the American Association of Pediatrics (AAP) in its contribution to the Choosing Wisely campaign. “Many coughs and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product.”
Bottom line: Wipe their noses by all means, but go easy on the cough syrup.
3. Do not do random allergy tests
A huge variety of symptoms are attributed to “food allergies”, though people are often unsure what they might be allergic to. But attributing symptoms like bloating, abdominal pains and weight loss to “allergy” can be misleading, and could mean a serious underlying condition is missed. If you suffer an allergic reaction, the key is to identify the culprit by recalling what you’ve eaten. Usually, there’s little doubt. If you vomit, swell up or nearly stop breathing when you eat poppy seeds, you don’t need a test to tell you you’re allergic. And if a blood test tells you that you’re allergic to peanuts but you can eat them with impunity, then you don’t need to avoid them. In fact, 8% of the population test positive to peanuts on allergy testing, but only 1% are truly allergic and get symptoms when they eat them.
Bottom line: Allergy tests are for people who have “proper” allergic reactions.
4. Do not medicate “happy spitters”
Babies are messy creatures. They spit up their milk, burp and cry. Some are diagnosed as having gastroesophageal reflux or GER. But if they are gaining weight and breathing OK, there is no need to medicalise or medicate them. “Parents should be counselled that GER is normal in infants and not associated with anything but stained clothes” says the AAP. Further investigation is only warranted if the baby is not thriving or has respiratory problems. Drugs that block acid (such as ranitidine) and act on the gut (such as metoclopramide) are commonly prescribed by paediatricians, especially in the private sector. But the experts says infant GER rarely causes any long term harm and that these drugs don’t help either in the short or long term.
Bottom line: Possetting (regurgitating milk) is normal for babies.
5. Do not advise taking St John’s wort for depression
According to Nice, there is evidence that St John’s wort (SJW) may help mild or moderate depression. Nevertheless, doctors should not prescribe it or even advise its use, because it is hard to be certain of the correct dose, there’s no standardised preparation and its effects can last variable lengths of time. SJW also interacts with lots of other drugs, including the contraceptive pill and blood-thinning drugs, such as warfarin.
Bottom line: Just because it works, doesn’t mean you should take it.
The problem with all these is that old habits die hard: doctors can go on a course to learn about new evidence, but it’s harder to change actual practice. For instance, Choosing Wisely says patients and doctors should question giving antibiotics to kids with ear infections if they’re not seriously unwell – the potential harm outweighs the benefits. But faced with a screaming kid and sleep-deprived parent, many GPs routinely prescribe antibiotics.
The campaign also says that there’s no need for a vaginal examination before starting the contraceptive pill. Routine but intrusive examinations are taught in medical schools but often have no real rationale. And several screening programmes also need to be challenged as they cause unecessary anxiety, and don’t really help. For instance, routine screening for prostate cancer by blood test or a digital rectal examination is of questionable value and men should only opt for screening if they’ve been fully informed about the pros and cons. So before tolerating a a needle in your arm or taking a prescription to the chemist, have a proper chat. It might just be one of those “do not dos”.
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