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General lnternal Medicine 2 High Value Care Recommendations The American College of Physicians, in collaboration with r Preoperative ECG should not be performed in patients multiple other organizations, is engaged in a worldwide undergoing low-risk procedures. initiative to promote the practice of High Value Care o Patients with coronary artery disease should not undergo (HVC). The goals of the HVC initiative are to improve routine coronary angiography or revascularization before health care outcomes by providing care ofproven benefit surgery exclusively to reduce perioperative events. and reducing costs by avoiding unnecessary and even r Chest radiography, arterial blood gas analysis, or spirom harmful interventions. The initiative comprises several etry is not routinely indicated in the preoperative evalua programs that integrate the important concept of health tion of patients with chronic lung disease (see Item 23). care value (balancing clinical benefit with costs and o There is no benefit of incentive spirometry with or with harms) for a given intervention into a broad range of out deep breathing exercises, in preventing postoperative educational materials to address the needs of trainees. pulmonary complications (see Item 111). practicing physicians, and patients. . Patients with untreated, asymptomatic mild hypothy roidism may proceed to surgery without further testing HVC content has been integrated into MKSAP 19 in sev or treatment. eral important ways. MKSAP 19 includes HVC-identified r Pregnant patients should undergo the same preoperative key points in the text, HVC-focused multiple-choice ques- medical evaluation as nonpregnant patients; additional tions, and, in MKSAP Digital, an HVC custom quiz. From diagnostic testing is unnecessary. the text and questions, we have generated the following list of HVC recommendations that meet the definition . There is little evidence that over-the-counter weight loss supplements are effective. below ofhigh value care and bring us closer to our goal of improving patient outcomes while conserving finite . Aspirin should be used infrequently in primary prevention of atherosclerotic cardiovascular disease (see Item 77). resources. r Routine screening for abdominal aortic aneurysm (AAA) High Value Care Recommendation: A recommendation to in women who have never smoked and who have no choose diagnostic and management strategies for patients family history of AAA is not recommended (see Item 97). in specific clinical situations that balance clinical benefit r Do not screen for coronary artery disease with either with cost and harms with the goal of improving patient resting or exercise ECG in asymptomatic patients at low outcomes. risk (see Item 22). Below are the High Value Care Recommendations for the r Clinicians should not use clinical breast examination to screen for breast cancer. General Internal Medicine 2 section of MKSAP 19. . Ultrasonography is preferred to mammography in the r The ordering ofexcessive tests and procedures to avoid evaluation of a breast mass in women younger than malpractice litigation leads to waste and potential harm 30 years. through unnecessary testing and treatment (see Item 84). o Routine laboratory testing for the diagnosis of menopause o Routine testing beyond the history and physical exam- is not recommended. ination is not necessary in the preparticipation physical o Nonhormonal therapies are preferred to topical vaginal examination (see Item 87). estrogen as first-line treatments for genitourinary syn- o The use of B-carotene or vitamin E supplements for the drome of menopause (see Item 1). prevention of cardiovascular disease or cancer is not . The preferred colorectal screening strate$/ is the one recommended. most likely to be completed by the patient (see Item 67). . Urinalysis is not indicated before joint arthroplasty in o Clinicians should not screen men for prostate cancer asymptomatic patients (see Item 30). unless they express a preference for screening (see o Patients whose Iaboratory test results in the past 4 months Item 106). were normal and whose clinical status is stable do not o Observation is recommended for uncomplicated acute need repeat testing before surgery (see Item 30). otitis media in adults and children. o Patients with less than 1% risk for perioperative major r Antibiotic therapy is ineffective in the treatment for the adverse cardiac event may proceed to surgery without common cold or acute rhinosinusitis and is not recom additional testing. mended (see Item 42).

General lnternal Medicine 2 High Value Care Recommendations The American College of Physicians, in collaboration with r Preoperative ECG should not be performed in patients multiple other organizations, is engaged in a worldwide undergoing low-risk procedures. initiative to promote the practice of High Value Care o Patients with coronary artery disease should not undergo (HVC). The goals of the HVC initiative are to improve routine coronary angiography or revascularization before health care outcomes by providing care ofproven benefit surgery exclusively to reduce perioperative events. and reducing costs by avoiding unnecessary and even r Chest radiography, arterial blood gas analysis, or spirom harmful interventions. The initiative comprises several etry is not routinely indicated in the preoperative evalua programs that integrate the important concept of health tion of patients with chronic lung disease (see Item 23). care value (balancing clinical benefit with costs and o There is no benefit of incentive spirometry with or with harms) for a given intervention into a broad range of out deep breathing exercises, in preventing postoperative educational materials to address the needs of trainees. pulmonary complications (see Item 111). practicing physicians, and patients. . Patients with untreated, asymptomatic mild hypothy roidism may proceed to surgery without further testing HVC content has been integrated into MKSAP 19 in sev or treatment. eral important ways. MKSAP 19 includes HVC-identified r Pregnant patients should undergo the same preoperative key points in the text, HVC-focused multiple-choice ques- medical evaluation as nonpregnant patients; additional tions, and, in MKSAP Digital, an HVC custom quiz. From diagnostic testing is unnecessary. the text and questions, we have generated the following list of HVC recommendations that meet the definition . There is little evidence that over-the-counter weight loss supplements are effective. below ofhigh value care and bring us closer to our goal of improving patient outcomes while conserving finite . Aspirin should be used infrequently in primary prevention of atherosclerotic cardiovascular disease (see Item 77). resources. r Routine screening for abdominal aortic aneurysm (AAA) High Value Care Recommendation: A recommendation to in women who have never smoked and who have no choose diagnostic and management strategies for patients family history of AAA is not recommended (see Item 97). in specific clinical situations that balance clinical benefit r Do not screen for coronary artery disease with either with cost and harms with the goal of improving patient resting or exercise ECG in asymptomatic patients at low outcomes. risk (see Item 22). Below are the High Value Care Recommendations for the r Clinicians should not use clinical breast examination to screen for breast cancer. General Internal Medicine 2 section of MKSAP 19. . Ultrasonography is preferred to mammography in the r The ordering ofexcessive tests and procedures to avoid evaluation of a breast mass in women younger than malpractice litigation leads to waste and potential harm 30 years. through unnecessary testing and treatment (see Item 84). o Routine laboratory testing for the diagnosis of menopause o Routine testing beyond the history and physical exam- is not recommended. ination is not necessary in the preparticipation physical o Nonhormonal therapies are preferred to topical vaginal examination (see Item 87). estrogen as first-line treatments for genitourinary syn- o The use of B-carotene or vitamin E supplements for the drome of menopause (see Item 1). prevention of cardiovascular disease or cancer is not . The preferred colorectal screening strate$/ is the one recommended. most likely to be completed by the patient (see Item 67). . Urinalysis is not indicated before joint arthroplasty in o Clinicians should not screen men for prostate cancer asymptomatic patients (see Item 30). unless they express a preference for screening (see o Patients whose Iaboratory test results in the past 4 months Item 106). were normal and whose clinical status is stable do not o Observation is recommended for uncomplicated acute need repeat testing before surgery (see Item 30). otitis media in adults and children. o Patients with less than 1% risk for perioperative major r Antibiotic therapy is ineffective in the treatment for the adverse cardiac event may proceed to surgery without common cold or acute rhinosinusitis and is not recom additional testing. mended (see Item 42). xltl

. Patients with acute pharyngitis who present with fewer o Topical antihistamines for urticaria are not recom- than three Centor criteria do not need to be tested or mended because they are ineffective and may lead to treated for bacterial pharyngitis. allergic contact dermatitis. o There is a generic equfualent in each class of topical r Pruritus may persist for weeks after eradication of scabies glucocorticoids, allowing for a cost-effective approach. and does not require retreatment. r Crmbined topical glucocorticoids and antifungal agents o Treatrnent of onychomycosis is unnecessary in most cases. should be avoided because they can worsen some tinea o Warts are usually self-limited and treatnent is unnecessary infections and may cause striae. o Perioperaflve glucocorticoid stress dosing may not be . Inexpensive treatment of seborrheic dermatitis includes required in many patients receiving low-dose and short- over-the-counter medications, such as selenium sulfide course glucocorticoid therapy (see Item 4). or zinc pyrithione shampoos. o The choice of a topical broad-qpectrum antibiotic for bacte- o Diagnostic evaluation for urticaria is not recommended rial conjunctivitis is usually empiric; the most c\cn/enient unless the history suggests a specific cause. or least expenshrc option can be selected (see Item 17). xtY

I General lnternal Medicine 2 I Routine Care of the Routine History and Physical Examination In the modern era of'technological advances, such as online Healthy Patient health messaging, electronic health records, ancl telemedicine. as 'well as physician time constraints and pressure to meet History and Physical Examination quality measures, the practice of medicine may seem more Periodic Health Examination depersonalized. Evidence reviews have identified good prac The periodic health examination is defined as a regular medi tices to enhance physician rapport and connection with cal visit, often on an annual basis, for the purposes ofscreen_ patients, most of which may not add significant time to the ing and prevention. Championed in the past by industry, visit and could potentially save time in the long run by setting insurance organizations, and organized medicine, the periodic expectations for visits and building trust. Useful strategies health examination has become an expectation of physicians include reviewing relerant information ahead of time, struc and patients alike. Patients have become accustomed to a com turing brief reflective pauses before each visit, providing a prehensive head to toe physical examination as well as rec warm greeting, mutually setting a clear agenda, and practicing ommendations fbr screening for disease, blood tests, and other active listening. routine testing. Although evidence suggests periodic health Obtaining a basic history as well as a fbcused history of examinations may improve surrogate outcomes, such as presenting problems is essential in establishing a clinician reduction in cardiovascular risk factors and increased receipt patient relationship and understanding the patient's health, of preventive services, there is no evidence that they reduce concerns, and expectations (Table l). Patients may be sensitive mortality or other patient important outcomes. A 2019 about sharing certain information, such as substance use and Cochrane systematic review confirmed that general health sexual practices; open and nonjudgmental communication checks may result in more new diagnoses but do not reduce can encourage sharing. Clinicians should preface these inquir morbidity, hospitalizations, or mortality. According to a 2OO7 ies by informing the patient that these questions are asked of estimate, periodic health examinations also have a substantial everyone, the information is necessary to provide the best financial impact, costing $5.2 billion annually without includ care, and responses are confidential. A focused history of'the ing costs ol additional testing, office visits, or missed work. primary reasons for the visit should also be obtained. It is often Overdiagnosis and overtreatment are other potential draw helpful to start with an open ended question or statement, backs to periodic health checks. The U.S. Preventive Services such as, "Tell me about your knee pain," which often results in Task Force (USPSTF), the Choosing Wisely campaign, and the more information sharing than does directive questioning. A Canadian Task Force on the Periodic Health Examination rec- commonly taught mnemonic to elicit other relevant informa ommend against performing general health checks that tion is OLDCARTS (Onset, Location/radiation, Duration. include a comprehensive examination and laboratory testing Character, Aggravating factors, Relieving factors, Timing, for asymptomatic adults. However, some countries, including Severity). It is often helpful to ask the patient, "What do you the United Kingdom, Germany, and Japan, continue to recom think is going on?" mend periodic health examinations. A focused physical examination should address the Despite the recommendation to avoid the periodic health patient's concems and relevant historical findings. Physical examination, the practice may offer value that is difficult to examination plays a large role in diagnosis. lrrespective of measure in clinical trials. It provides dedicated time for screen gender presentation, physicians should provide care for the ing, immunizations, and healthy lifestyle counseling and may present anatomy in a sensitive, respectful, and affirming man- strengthen physician patient relationships and patient adher ner. Regularly obtaining height and weight (to calculate BMI) ence to physician recommendations. In 2011, Medicare intro as well as blood pressure is universally recommended. In addi duced an annual wellness visit to develop or update a tion, pulse palpation in individuals older than 65 years has personalized prevention plan; however, a study ofthese visits been found effective for detection of atrial librillation. ln did not show improvements in care. In practices that do not asymptomatic patients, the USPSTF recommends against rou routinely use periodic health examinations, automated tine abdominal, testicular, and bimanual pelvic examinations reminder systems, online portals, and clinical assistants can fbr cancer screening. Routine cardiac and lung auscultation, help prompt receipt of indicated preventive services to patients thyroid palpation, skin examination, visual acuity assessment, at home or during focused visits. and hearing assessment may be appropriate as part of a

Routine Care of the Routine History and Physical Examination In the modern era of'technological advances, such as online Healthy Patient health messaging, electronic health records, ancl telemedicine. as 'well as physician time constraints and pressure to meet History and Physical Examination quality measures, the practice of medicine may seem more Periodic Health Examination depersonalized. Evidence reviews have identified good prac The periodic health examination is defined as a regular medi tices to enhance physician rapport and connection with cal visit, often on an annual basis, for the purposes ofscreen_ patients, most of which may not add significant time to the ing and prevention. Championed in the past by industry, visit and could potentially save time in the long run by setting insurance organizations, and organized medicine, the periodic expectations for visits and building trust. Useful strategies health examination has become an expectation of physicians include reviewing relerant information ahead of time, struc and patients alike. Patients have become accustomed to a com turing brief reflective pauses before each visit, providing a prehensive head to toe physical examination as well as rec warm greeting, mutually setting a clear agenda, and practicing ommendations fbr screening for disease, blood tests, and other active listening. routine testing. Although evidence suggests periodic health Obtaining a basic history as well as a fbcused history of examinations may improve surrogate outcomes, such as presenting problems is essential in establishing a clinician reduction in cardiovascular risk factors and increased receipt patient relationship and understanding the patient's health, of preventive services, there is no evidence that they reduce concerns, and expectations (Table l). Patients may be sensitive mortality or other patient important outcomes. A 2019 about sharing certain information, such as substance use and Cochrane systematic review confirmed that general health sexual practices; open and nonjudgmental communication checks may result in more new diagnoses but do not reduce can encourage sharing. Clinicians should preface these inquir morbidity, hospitalizations, or mortality. According to a 2OO7 ies by informing the patient that these questions are asked of estimate, periodic health examinations also have a substantial everyone, the information is necessary to provide the best financial impact, costing $5.2 billion annually without includ care, and responses are confidential. A focused history of'the ing costs ol additional testing, office visits, or missed work. primary reasons for the visit should also be obtained. It is often Overdiagnosis and overtreatment are other potential draw helpful to start with an open ended question or statement, backs to periodic health checks. The U.S. Preventive Services such as, "Tell me about your knee pain," which often results in Task Force (USPSTF), the Choosing Wisely campaign, and the more information sharing than does directive questioning. A Canadian Task Force on the Periodic Health Examination rec- commonly taught mnemonic to elicit other relevant informa ommend against performing general health checks that tion is OLDCARTS (Onset, Location/radiation, Duration. include a comprehensive examination and laboratory testing Character, Aggravating factors, Relieving factors, Timing, for asymptomatic adults. However, some countries, including Severity). It is often helpful to ask the patient, "What do you the United Kingdom, Germany, and Japan, continue to recom think is going on?" mend periodic health examinations. A focused physical examination should address the Despite the recommendation to avoid the periodic health patient's concems and relevant historical findings. Physical examination, the practice may offer value that is difficult to examination plays a large role in diagnosis. lrrespective of measure in clinical trials. It provides dedicated time for screen gender presentation, physicians should provide care for the ing, immunizations, and healthy lifestyle counseling and may present anatomy in a sensitive, respectful, and affirming man- strengthen physician patient relationships and patient adher ner. Regularly obtaining height and weight (to calculate BMI) ence to physician recommendations. In 2011, Medicare intro as well as blood pressure is universally recommended. In addi duced an annual wellness visit to develop or update a tion, pulse palpation in individuals older than 65 years has personalized prevention plan; however, a study ofthese visits been found effective for detection of atrial librillation. ln did not show improvements in care. In practices that do not asymptomatic patients, the USPSTF recommends against rou routinely use periodic health examinations, automated tine abdominal, testicular, and bimanual pelvic examinations reminder systems, online portals, and clinical assistants can fbr cancer screening. Routine cardiac and lung auscultation, help prompt receipt of indicated preventive services to patients thyroid palpation, skin examination, visual acuity assessment, at home or during focused visits. and hearing assessment may be appropriate as part of a 1