Internal medicine

Five Things Physicians and Patients Should Question

Released April 2, 2014


Don’t routinely obtain neuro-imaging studies (CT, MRI, or carotid dopplers) in the evaluation of simple syncope in patients with a normal neurological examination.

Although an uncommon cause for syncope, providers must consider a neurological cause in every patient presenting with transient loss of consciousness. In the absence of signs or symptoms concerning for neurological causes of syncope (such as but not limited to focal neurological deficits), the utility of neuro-imaging studies are of limited benefit. Despite a lack of evidence for the diagnostic utility of neuroimaging in patients presenting with true syncope, providers continue to perform brain computed tomographic (CT) scans. Thus, inappropriate use of this diagnostic imaging modality carries high costs and subject patients to the risks of radiation exposure.


Don’t place, or leave in place, urinary catheters without an acceptable indication (such as critical illness, obstruction, palliative care).

Use of urinary catheters without an acceptable indication of use increases the likelihood of infection leading to greater morbidity and health care costs. Catheter-associated bacteriuria often leads to inappropriate antimicrobial use and secondary complications including emergence of antimicrobial-resistant organisms and infection with clostridium difficile. A previous study showed that physicians are often unaware of urinary catheterization among their patients. Use of urinary catheters has found to be inappropriate in up to 50% of cases, with urinary incontinence listed as the most common reason for inappropriate and continued placement of urinary catheters. Clinical practice guidelines support the removal or avoidance of unnecessary urinary catheters in order to reduce the risk of catheter-associated urinary tract infections (CAUTIs).


Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke.

Indications for blood transfusion depend on clinical assessment and are also guided by the etiology of the anemia. No single laboratory measurement or physiologic parameter can predict the need for blood transfusion. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Adverse events range from mild to severe, including allergic reactions, acute hemolytic reactions, anaphylaxis, transfusion related acute lung injury, transfusion associated circulatory overload, and sepsis. Studies of transfusion strategies among multiple patient populations suggest that a restrictive approach is associated with improved outcomes.


In the inpatient setting, don’t order repeated CBC and chemistry testing in the face of clinical and lab stability.

Repetitive inpatient blood testing occurs frequently and is associated with adverse consequences for the hospitalized patient such as iatrogenic anemia, and pain. A Canadian study showed significant hemoglobin reductions as a result of phlebotomy. Given that anemia in hospital patients is associated with increased length of stay, readmission rates and transfusion requirements, reducing unnecessary testing may improve outcomes. Studies support the safe reduction of repetitive laboratory testing without negative effects on adverse events, readmission rates, critical care utilization or mortality. Laboratory reduction interventions have also reported significant cost savings.


Don’t routinely perform preoperative testing (such as chest X-rays, echocardiograms, or cardiac stress tests) for patients undergoing low risk surgeries.

Routine preoperative tests for low risk surgeries results in unnecessary delays, potential distress for patients and significant cost for the health care system. Numerous studies and guidelines outline lack of evidence for benefit in routine preoperative testing (e.g., chest X-ray, echocardiogram) in low risk surgical patients. Economic analyses suggest significant potential cost savings from implementation of guidelines.

How the list was created

The Canadian Society of Internal Medicine (CSIM) established its Choosing Wisely Canada Top 5 recommendations by convening a Committee of 20 members that represent a diverse group of general internists from across Canada, reflecting a broad range of geographical regions, practice settings, institution types and experience. The Committee chose to adopt pre-existing recommendations that have already undergone rigorous evidence review from the Five Things Physicians and Patients Should Question (© 2013 American College of Physicians; © 2012 Society of Hospital Medicine; © 2013 Society of General Internal Medicine), the American College of Physicians High Value Cost Conscious Care recommendations, and the “do not do” recommendations from the National Institute for Health and Care Excellence (NICE) in the United Kingdom. In addition, members brought forward recommendations based on experience and relevance to practice. Each Committee member was invited to anonymously rank all recommendations online. The Committee discussed the highest ranked recommendations and reached a consensus on a list of Top 5 items. The list of recommendations was presented at an open forum CSIM meeting and to the Executive Council at the 2013 CSIM Annual Meeting in Toronto, Canada. CSIM members who attended the Council meeting and the Choosing Wisely Update session were also given an opportunity to provide feedback. Minor refinements to the list were made and subsequently approved by the Committee. The CSIM Executive Council provides full endorsement and support for the final list of CSIM Choosing Wisely Canada recommendations.



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Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504.

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