“Things Providers and Patients Should Question.”

The mission of "Choosing Wisely" is to promote conversations between clinicians and patients by helping patients choose care that is:

Supported by evidence
Not duplicative of other tests or procedures already received
Free from harm
Truly necessary

Beginning in 2012, national organizations representing medical specialists have asked their members to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed. This call to action has resulted in specialty-specific lists of  “Things Providers and Patients Should Question.”

The original list was compiled the American Academy of Family Physicians

Don’t do imaging for low back pain within the first six weeks, unless

red flags are present.

Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis

are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most

common reason for all physician visits.

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.

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due

to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80

percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

Don’t use dual-energy x-ray absorptiometry (DEXA) screening

for osteoporosis in women younger than 65 or men younger than

70 with no risk factors.

DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients

Don’t order annual electrocardiograms (EKGs) or any other cardiac

screening for low-risk patients without symptoms.

There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health

outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential

harms of this routine annual screening exceed the potential benefit.

Don’t perform Pap smears on women younger than 21 or who have

had a hysterectomy for non-cancer disease.

Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety,

additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for

improved outcomes.

– Nine leading physician specialty societies have identified specific tests or procedures that they say are commonly used but not always necessary in their respective fields. Patient advocates are calling the move a significant step toward improving the quality and safety of health care.

 The lists include things to question such as:

Do patients need brain imaging scans like a computed tomography (CT) or magnetic resonance imaging (MRI) after fainting, also known as simple syncope? Probably not. Research has shown that, with no evidence of seizure or other neurologic symptoms during an exam, patient outcomes are not improved with brain imaging studies. (American College of Physicians)

Do patients need stress imaging tests for annual checkups? Not if you are an otherwise healthy adult without cardiac symptoms. These tests rarely result in any meaningful change in patient management. (American College of Cardiology)
Should patients going into outpatient surgery receive a chest x-ray beforehand? If the patient has an unremarkable history and physical exam, then no. Most of the time these images will not result in a change in management and has not been shown to improve patient outcomes. (American College of Radiology)

Do patients need a CT scan or antibiotics for acute sinusitis? Most acute rhinosinusitis resolves without treatment in two weeks and when uncomplicated is generally diagnosed clinically and does not require a sinus CT scan or other imaging. (American Academy of Allergy, Asthma & Immunology)

Should dialysis patients who have limited life expectancies and no signs or symptoms of cancer get routine cancer screening tests? These tests do not improve survival in dialysis patients with limited life expectancies, and can cause false positives which might lead to harm, overtreatment and unnecessary stress. (American Society of Nephrology)

Should women under 65 or men under 70 be screened for osteoporosis with dual energy x-ray absorptiometry (DEXA)? No, research has shown that in patients with no risk factors, DEXA screening is not helpful in this age group. (American Academy of Family Physicians)

Since 2012 when the list was established it has grown substantially and many common tests performed regularly are on it.  This by no means that those tests should not be done. They must be considered in a larger framework of history, family history, physical examination and some routine blood tests.


To help patients engage their health care provider in these conversations and empower them to ask questions about what tests and procedures are right for them, patient-friendly materials were created based on the specialty societies’ lists of recommendations of tests and treatments that may be unnecessary.

The choosing wisely list was compiled by a large number of medical specialty societies.

Note: Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.


The list has been duplicated and disseminated by numerous consumer oriented publications

Ref:  Choosing Wisely.