When a test isn't best.

How do doctors decide on tests and treatments for their patients? Most people would like to believe that such decisions are made on the basis of available evidence, and that only appropriate investigations and interventions are done. But often this is not the case, with many widely used tests and procedures unsupported by evidence, duplicative of others already used, unnecessary and wasteful, or even potentially harmful. The problem can be particularly acute in the US, where the structure of the private health-care system creates a perverse incentive in favour of medically unnecessary tests and procedures, which in turn adds to escalating costs. In this context, the Choosing Wisely campaign from the American Board of Internal Medicine Foundation has been a welcome development. Working together with a coalition of medical specialty societies and health-based consumer organisations, on Feb 21 the foundation published a revised list of more than 130 tests, procedures, and drug treatments that “physicians and patients should question”. Each of the 17 specialty societies has produced a list of fi ve or more recommendations, along with supporting evidence. Recommendations include not to use electroencephalography for headaches (since it has no advantage over clinical assessment); not to do MRI of the peripheral joints to monitor infl ammatory arthritis routinely; not to do cardiac imaging for patients who are at low risk; and not to schedule elective, non-medicallyindicated inductions of labour or caesarean deliveries before 39 weeks. The organisation Consumer Reports has been working as part of the campaign to produce easy-to-understand materials for patients, to allow them to question specifi c tests and procedures. Although worthwhile, the onus should instead be on doctors to ensure that they—and their trainees—request only relevant tests, and deliver only scientifi cally proven treatments. As such, Choosing Wisely is a valuable resource for clinicians and for policy makers charged with tackling runaway health-care costs, in the US and elsewhere. It should not be ignored. The Lancet For the full list of recommendations see http:// www.choosingwisely.org/wpcontent/uploads/2013/02/ Choosing-Wisely-Master-List.pdf