Doc Talk #154 – Clinical Appropriateness

Continuing to unearth the (not so) long lost archives, we delve into the topic of clinical appropriateness in this show.

One of the challenges of medicine based on scientific principles, is that the evidence has a pesky habit of changing. The medical dogma of today is at risk of being the medical myth of tomorrow.

Happily there are a whole bunch of clever people, including physicians, academics, scientists and others who regularly look at the evolving evidence and provide healthcare professionals with guidance. This includes the amazing folks contributing to Choosing Wisely Canada.

Dr Dan: If you and I have an MRI of our backs now Jamieson, do you what it will show?

Jamieson: Nothing?

Dr Dan: No it will show our backs are shot. MRI findings are extremely common even in people who don’t have any symptoms.

MRI findings in patients with no symptoms – from the work of Brinjiki et al. (2014) – full paper available at

We discussed the top 13 recommendations in family medicine from Choosing Wisely and practices that should be questioned:

  • Imaging for lower back pain
  • Antibiotics for upper respiratory tract infections
  • Routine ECGs (heart recordings) and chest X-rays for people without symptoms
  • Pap tests under the age of 21 or over the age of 69
  • Annual blood tests (unless there is a specific reason)
  • Vitamin D testing in low risk patients
  • Mammograms for average risk women under the age of 50
  • Annual physical exams on asymptomatic adults
  • Bone density testing in low risk adults
  • Routine monitoring of blood glucose with fingerprick testing in patients with type 2 diabetes who are not on insulin
  • Routine thyroid tests in patients without symptoms
  • Prolonged use of opioids following surgery
  • Opioid painkillers for chronic pain

All of these recommendations are general guidelines and don’t apply to everyone, but if you see something on this list that is relevant to you, then it would be well worth a conversation with your doctor!

Chest X-ray image by Yale Rosen from USA [CC BY-SA 2.0 (

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