To Pap or NOT to Pap?

Choosing Wisely is a wonderful campaign aimed at increasing discussions between doctors and patients about tests and procedures, and what is expected versus what has been shown to be effective. I am starting my focus on this campaign with highlighting the recommendations of my academy- the AAFP (American Academy of Family Physicians.) So far, I've discussed back x-rays, sinusitis treatment, bone density tests and EKGs, and today I would like to address Pap tests.

Pap tests do a wonderful job in helping us detect cervical cancer in early, very treatable stages. With our increased understanding of this disease being caused by HPV (the Human Papilloma Virus) as well as improving technology that allows us to detect the specific strains of HPV that are high risk for cancer, we are changing the recommendations for Pap tests on what seems like an annual basis. This recommendation focuses on two parts: Girls under the age of 21 and women who have had hysterectomies for reasons other than cancer (such as fibroids or heavy bleeding) do NOT need Pap tests. Evidence has shown that the vast majority of teens who are infected with HPV will not progress to cancer, but instead effectively "clear" the infection within a few years (meaning the HPV lowers to an undetectable level, though it still may be present.) Likewise, the incidence of cancer in women who have had their uterus removed for non-cancerous reasons is so small that there is little evidence for improved outcomes.

As a major proponent of sexually transmitted disease awareness, however, I want to be crystal clear that women under the age of 21 STILL NEED TESTING for STDs if they are having sex! No Pap does NOT equal no testing or no exam.

BOTTOM LINE: Pap testing recommendations are changing frequently- please talk with your doctor about the most current recommendations and do not be surprised if you do NOT need one this year!

Choose Wisely: An EKG?

Should an EKG (electrocardiogram- the heart tracing) be a ROUTINE part of your annual physical? NO- not unless you have risk factors that suggest otherwise! I am blogging this month about the American Academy of Family Physician's recommendations for tests and procedures that patients and doctors should question. The Choosing Wisely campaign is focusing attention across specialties to look at evidence-based recommendations that should be discussed to help make better decisions for patient health & health dollars.

So what about the heart tracing? Well, it turns out that there is little evidence that pure screening EKGs in healthy, low-risk people will pick up silent coronary heart disease and subsequently prevent heart attacks. Instead, what we see is a moderate number of false-positive tests that lead to additional unnecessary and often invasive procedures.

Who SHOULD get EKG's? Risk factors for coronary disease include high blood pressure, high "bad" (LDL) cholesterol or low "good" (HDL) cholesterol, smoking, family history of heart disease, diabetes, males over age 45 & women over 55, and obesity. The more risk factors you have, the higher your risk, and the more likely it is that your doctor will indeed recommend an EKG at your office visit.

Check out the other AAFP Recommendations: Bone Density Test, Sinus Infection treatment, and Back X-rays

BOTTOM LINE: ROUTINE EKGs in healthy, low risk patients are unnecessary and possibly harmful- skip this test unless you & your doctor determine you are at risk for heart disease!

Bone Densities- Really Necessary?

As part of the Choosing Wisely campaign, the American Academy of Family Physicians has released our top five recommendations for tests and procedures that patients and doctors should question. Today, I am focusing on the third issue: bone densities. The recommendation is this:

Do not use dual-emission X-ray absorptiometry (DEXA) in women younger than age 65 or men younger than 70 with no risk factors.

We now know that using these bone density scans are not cost-effective in younger, low risk patients. This simply means we do not need to ROUTINELY do bone densities as part of the well woman exam each year. Please note that I did NOT say NEVER to use this test! In patients with risk factors for thinning bones, bone densities can give us excellent information.
What are risk factors?
--Family history of osteoporosis (Do you have tiny, hunched over, little old ladies for grandparents?)
--Thyroid disease (especially people who have been over-replaced for under active thyroid disease)
--Smoking
--Excessive alcohol intake (>2/day)
--History of a fracture without having trauma
--Age over 65 and Female, or 70 & Male
--Caucasian or Asian
If you have one, or especially, several of these risk factors, your doctor may indeed suggest getting a bone density test, and she should!

BOTTOM LINE: Bone density testing should not be a ROUTINE screen for everyone, but reserved for those with risk factors.

Does Your Sinus Infection Need Antibiotics?

Item number two on the “Choosing Wisely” campaign to educate doctors and patients on unnecessary tests is the toughest one of all- “Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.”

For years doctors have known that the majority of sinusitis infections are caused by viruses. We know that antibiotics do NOT cure viral infections, only bacterial ones. Why, then, do many doctors continue to prescribe antibiotics for this problem? Why do patients ask for an antibiotic even when the doctor takes the time to explain that an antibiotic is unlikely to help? Americans spend over $5.8 BILLION health care dollars on this common diagnosis via 16 MILLION office visits and medication costs.

Have I ever prescribed antibiotics for this? You bet- especially on a Friday, or when a patient is headed out of town! BUT…let me explain why and how. As a busy mom, I understand the exasperation of a lingering runny, stuffy nose and headache, and the desire for a simple cure to “fix it”- whether those symptoms are mine or my husband’s or kid’s. If I take the time to schedule an appointment, show up, and wait because the doctor is running late, I want to get my money and time’s worth and be handed a cure. The doctor wants to be able to give you this cure. Both parties can feel like they are “doing something” when the doctor prescribes the antibiotics. And sometimes it seems that once we take that antibiotic, then, indeed the symptoms go right away. However, from good research, we know this is the exception, and not the rule.

Given all these factors, here is my approach. If I examine a patient and believe they have a mild to moderate sinus infection that has lasted only a few days, I frequently offer them two prescriptions: one for something to help with the symptoms (such as a drying antihistamine, if a runny nose is a major complaint, or a decongestant and something to break up mucus if they are stuffy with thick nasal discharge); and the second one a prescription for an antibiotic. BUT- I ask them not to fill the antibiotic prescription for a couple days, explaining why it is unlikely to help unless their symptoms drag on or they get signs of a secondary infection such as fevers or local pain in their teeth or forehead. I encourage them to hydrate till they float, and to use old -fashioned topical vapor rubs or sip spicy soups to open nasal passages. I have found that the vast majority of the time, when we follow up with our patient, they report they never needed to fill that second prescription (for the antibiotic) and we all feel as though we’ve done something productive.

BOTTOM LINE: Most sinus infections will resolve without antibiotics- talk with your doctor about treatment options that will help your symptoms, but don’t insist on an antibiotic.

An Xray for Your Aching Back?

Last week, the “Choosing Wisely” campaign was unveiled to physicians and patients alike. The concept was for each major specialty to identify five interventions that traditionally, physicians have ordered (and patients have expected) yet now evidenced-based medicine is telling us that these are simply unnecessary, not truly beneficial, and/or costly in dollars or health. For the next week, I would like to add my two cents worth for each of the five interventions highlighted by my academy- the American Academy of Family Physicians.

The first recommendation is to AVOID IMAGING (x-rays, CT or MRI scans) for LOW BACK PAIN that has been present less than six weeks
Did you know that low back pain is the 5th most common reason that people head to their doctor? We “throw out” our backs at an amazing rate, and it’s usually just from bending over or vacuuming more than moving baby grand pianos. The vast majority of low back pain is muscular, and a combination of anti-inflammatory medications (like ibuprofen), topical modalities (heat & massage) and judicious use of muscle relaxants-plus TIME measured in days, not hours- will take care of the problem. Ergonomic evaluations and physical therapy can also do wonders for low back pain, especially if it is recurrent. Insisting on an x-ray or fancy scan will certainly reduce the thickness of your wallet, but is unlikely to reduce your pain.

BOTTOM LINE: Hold off on x-rays or other scans for low back pain unless your pain has persisted more than six weeks, or your doctor sees “red flags” that suggest less common, more serious underlying issues.