American College of Physicians

Five Things Physicians and Patients Should Question

Released April 4, 2012; Last reviewed 2019

  1. 1

    Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.

    In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%) screening for coronary heart disease with exercise electrocardiography does not improve patient outcomes.

  2. 2

    Don’t obtain imaging studies in patients with non-specific low back pain.

    In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.

  3. 3

    In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).

    In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low and patient outcomes are not improved with brain imaging studies.

  4. 4

    In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

    In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.

  5. 5

    Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

    In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American College of Physicians (ACP) is the largest medical specialty organization and the second-largest physician group in the U.S. ACP’s 132,000 members include internal medicine physicians (internists), subspecialists, and medical students. Internists specialize in the prevention, detection, and treatment of illness in adults. ACP’s mission is to enhance the quality of health care by fostering excellence and professionalism in medicine. ACP provides information and advocacy for its members in internal medicine and related subspecialties.

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How This List Was Created

The American College of Physicians (ACP) formed a workgroup of eleven experienced internal medicine physicians with specific skills in the assessment of evidence. Members of this workgroup included physicians who were current members of the ACP Clinical Guidelines Committee, the Education and Publication Committee, the Board of Governors and the Board of Regents, as well as three ACP staff physicians. The group collaboratively identified and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. The results were further reviewed and narrowed by clinically active ACP staff physicians before being placed for review into a randomly selected internal medicine research panel. Representing 1 percent of ACP members, the panel selected five scenarios that represented the greatest potential for overuse or misuse of a diagnostic test leading to low value care. Based upon this process, the final top five scenarios were identified.

ACP’s disclosure and conflict of interest policy can be found at


  1. 2011 USPSTF screening for coronary heart disease with electrocardiography (draft) guideline; 2011 AAFP recommendations for preventive services guideline; 2010 ACCF/AHA assessment of cardiovascular risk in asymptomatic adults guideline.

  2. 2009 NICE low back pain guideline; 2008 ACR Appropriateness Criteria® low back pain guideline; 2007 ACP/APS low back pain guideline; 2007 ACOM low back disorders guideline.

  3. 2010 ACR-ASNR CT of the brain guideline; 2010 NICE transient loss of consciousness guideline; 2000 ECS syncope guideline.

  4. 2011 ACEP pulmonary embolism guideline; 2008 ESC pulmonary embolism guideline; 2007 AAFP/ACP venous thromboembolism guideline; 2010 SIGN venous thromboembolism guideline.

  5. 2008 ACR Appropriateness Criteria® for preoperative chest radiography guideline; ASPC patient safety advisory for pulmonary complications of surgery.