Journal of General Internal Medicine

, Volume 34, Issue 8, pp 1475–1485 | Cite as

The French Society of Internal Medicine’s Top-5 List of Recommendations: a National Web-Based Survey

  • Nathan Peiffer-SmadjaEmail author
  • Adeline Bauvois
  • Marie Chilles
  • Baptiste Gramont
  • Redwan Maatoug
  • Marie Bismut
  • Camille Thorey
  • Eric Oziol
  • Thomas Hanslik



The international project “Choosing Wisely” aims to target unnecessary and potentially harmful examinations and treatments.


To define the French Internal Medicine Top-5 list.


Based on a review of existing Top-5 lists and personal experience, a working group of the French National Society of Internal Medicine selected 27 diagnostic and therapeutic procedures. They were submitted through a national web-based survey to French internists who rated from 1 to 5 the perceived frequency, uselessness, and risk of each procedure. A composite score was calculated as the unweighted addition of the three scores.


Four hundred thirty internists answered the web-based survey (14% of all French internists including residents). All the French regions and status of the profession were represented.

Key Results

For the 27 submitted procedures, the mean score (± SD) was 3.25 (± 0.48) for frequency, 3.10 (± 0.43) for uselessness, and 2.63 (± 0.84) for risk.

The Top-5 list obtained with the composite score was as follows:
  1. 1.

    Do not prescribe long-term treatment with proton pump inhibitors without regular reevaluation of the indication

  2. 2.

    Do not administer preventive treatments (e.g., for dyslipidemia, hypertension…) in elderly people with dementia when potential risks outweigh the benefits

  3. 3.

    Do not administer hypnotic medications as first-line treatment for insomnia

  4. 4.

    Do not treat with an anticoagulant for more than 3 months a patient with a first venous thromboembolism occurring in the setting of a major transient risk factor

  5. 5.

    Do not screen for Lyme disease without an exposure history or related clinical examination findings


We found that the composite score was strongly correlated to the risk score (rs = 0.88, p < 10−5) and not to the frequency (rs = 0.06, p = 0.75) or uselessness score (rs = 0.17, p = 0.38).


This Top-5 list provides an opportunity to discuss appropriate use of health care practices in internal medicine.


Choosing Wisely overmedicalization internal medicine inappropriate prescribing 



We thank the SNFMI (French National Society of Internal Medicine) and the Junior Internist Association (AJI) for their support for this work.

We thank the FHF (Fédération Hospitalière de France) and the EFIM (European Federation of Internal Medicine) which were at the origin of this work.

We thank Thibaud Pitel and the Sentinelles network for their assistance in carrying out the web-based survey.

We thank the volunteers who tested the website and all the participants in the survey.

We are grateful to three anonymous reviewers whose insight improved this article.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


  1. 1.
    Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci 2014;9:1. Scholar
  2. 2.
    Grady D, Redberg RF. Less is more: how less health care can result in better health. Arch Intern Med 2010;170(9):749–750. Scholar
  3. 3.
    Too much medicine. Br Med J. Accessed 25 Oct 2017.
  4. 4.
    Sox H, Blank L, Cohen J, ABIM Foundation. American Board of Internal Medicine, Foundation A-A, Medicine AC of P-AS of IMEF of I. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136(3):243–246.CrossRefGoogle Scholar
  5. 5.
    Volpp KG, Loewenstein G, Asch DA. Choosing wisely: low-value services, utilization, and patient cost sharing. JAMA. 2012;308(16):1635–1636. Scholar
  6. 6.
    Chow SL, Carter Thorne J, Bell MJ, et al. Choosing wisely: the Canadian Rheumatology Association’s list of 5 items physicians and patients should question. J Rheumatol 2015;42(4):682–689. Scholar
  7. 7.
    Malhotra A, Maughan D, Ansell J, et al. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ. 2015;350:h2308.CrossRefGoogle Scholar
  8. 8.
    Vogel L. Choosing Wisely around the world. CMAJ. 2015;187(11):E341–2. Scholar
  9. 9.
    Conseil National de l’Ordre des Médecins. Atlas de La Démographie Médicale En France.; 2016.Google Scholar
  10. 10.
    Rapports à la Comission des comptes de la sécurité sociale. Les Prescriptions d’IPP.; 2009.
  11. 11.
    Freedberg DE, Kim LS, Yang Y-X. The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017;152(4):706–715. Scholar
  12. 12.
    Boghossian TA, Rashid FJ, Thompson W, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev 2017;3:CD011969. Scholar
  13. 13.
    Sheen E, Triadafilopoulos G. Adverse effects of long-term proton pump inhibitor therapy. Dig Dis Sci 2011;56(4):931–950. Scholar
  14. 14.
    Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician 2017;63(5):354–364.PubMedPubMedCentralGoogle Scholar
  15. 15. Evidence-based deprescribing algorithm for proton pump inhibitors. Published 2016. Accessed 28 Nov 2017.
  16. 16.
    Narayan SW, Nishtala PS. Discontinuation of Preventive Medicines in Older People with Limited Life Expectancy: A Systematic Review. Drugs Aging 2017;34(10):767–776. Scholar
  17. 17.
    US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. JAMA. 2016;316(19):1997. Scholar
  18. 18.
    Tinetti ME, Han L, Lee DSH, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med 2014;174(4):588–595. Scholar
  19. 19.
    Morin L, Vetrano DL, Rizzuto D, Calderon-Larranaga A, Fastbom J, Johnell K. Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study. Am J Med 2017;130(8):927–936.e9. Scholar
  20. 20.
    Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166(6):605–609. Scholar
  21. 21.
    Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res 2017. Scholar
  22. 22.
    Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med 2008;3(6):473–482. Scholar
  23. 23.
    Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. J Am Geriatr Soc 2011;59(10):1883–1890. Scholar
  24. 24.
    Glass J. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005;331(7526):1169–0. Scholar
  25. 25.
    Airagnes G, Pelissolo A, Lavallée M, Flament M, Limosin F. Benzodiazepine Misuse in the Elderly: Risk Factors, Consequences, and Management. Curr Psychiatry Rep 2016;18(10).
  26. 26.
    Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2016;165(2):125–133. Scholar
  27. 27.
    Boutitie F, Pinede L, Schulman S, et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants’ data from seven trials. BMJ. 2011;342:d3036.CrossRefGoogle Scholar
  28. 28.
    Middeldorp S, Prins MH, Hutten BA. Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism. Cochrane Database Syst Rev 2014;(8):CD001367.
  29. 29.
    Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S-e496S. Scholar
  30. 30.
    Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol 2012;87 Suppl 1:S63–7. Scholar
  31. 31.
    Ley C, Le C, Olshen EM, Reingold AL. The use of serologic tests for Lyme disease in a prepaid health plan in California. JAMA. 1994;271(6):460–463.CrossRefGoogle Scholar
  32. 32.
    Dessau RB, van Dam AP, Fingerle V, et al. To test or not to test? Laboratory support for the diagnosis of Lyme borreliosis: a position paper of ESGBOR, the ESCMID study group for Lyme borreliosis. Clin Microbiol Infect 2017. Scholar
  33. 33.
    Coumou J, Hovius JWR, van Dam AP. Borrelia burgdorferi sensu lato serology in the Netherlands: guidelines versus daily practice. Eur J Clin Microbiol Infect Dis 2014;33(10):1803–1808. Scholar
  34. 34.
    Lantos PM, Branda JA, Boggan JC, et al. Poor Positive Predictive Value of Lyme Disease Serologic Testing in an Area of Low Disease Incidence. Clin Infect Dis 2015;61(9):1374–1380. Scholar
  35. 35.
    Marzec NS, Nelson C, Waldron PR, et al. Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease - United States. MMWR Morb Mortal Wkly Rep 2017;66(23):607–609. Scholar
  36. 36.
    Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43(9):1089–1134. Scholar
  37. 37.
    Markowicz M, Kivaranovic D, Stanek G. Testing patients with non-specific symptoms for antibodies against Borrelia burgdorferi sensu lato does not provide useful clinical information about their aetiology. Clin Microbiol Infect 2015;21(12):1098–1103. Scholar
  38. 38.
    Horvath K, Siebenhofer A. The Choosing Wisely Initiative: A critical analysis with a special focus on primary care. Z Evid Fortbild Qual Gesundh Wes 2017. Scholar
  39. 39.
    Lin KW, Yancey JR. Evaluating the Evidence for Choosing Wisely TM in Primary Care Using the Strength of Recommendation Taxonomy (SORT). JABFM. 2016;29(4):512–515. Scholar
  40. 40.
    Cho HJ, Wray CM, Maione S, et al. Right Care in Hospital Medicine: Co-creation of Ten Opportunities in Overuse and Underuse for Improving Value in Hospital Medicine. J Gen Intern Med 2018;33(6):804–806. Scholar
  41. 41.
    Montano N, Costantino G, Casazza G, et al. The Italian Society of Internal Medicine choosing wisely campaign. Intern Emerg Med 2016;11(8):1125–1130. Scholar
  42. 42.
    Livingston CJ, Freeman RJ, Mohammad A, et al. Choosing Wisely(R) in Preventive Medicine: The American College of Preventive Medicine’s Top 5 List of Recommendations. Am J Prev Med 2016;51(1):141–149. Scholar
  43. 43.
    Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med 2013;8(9):486–492. Scholar
  44. 44.
    McMahon LFJ, Beyth RJ, Burger A, et al. Enhancing patient-centered care: SGIM and choosing wisely. J Gen Intern Med 2014;29(3):432–433. Scholar
  45. 45.
    Gupta S, Detsky AS. Development of choosing wisely recommendations for an inpatient internal medicine service. JAMA Intern Med 2015;175(4):642–644. Scholar
  46. 46.
    ABIM Foundation. American Board of Internal Medicine. Choosing Wisely. Accessed 25 Oct 2017.
  47. 47.
    Lee IT, Di Capua J, Cho HJ. Considering Cocreation for the Choosing Wisely List. Acad Med 2017;92(5):576. Scholar
  48. 48.
    Levinson W, Born K, Wolfson D. Choosing Wisely Campaigns: A Work in Progress. JAMA. 2018;319(19):1975–1976. Scholar
  49. 49.
    Shih T-H, Fan X. Comparing Response Rates from Web and Mail Surveys: A Meta-Analysis. Field Methods 2008;20(3):249–271. Scholar
  50. 50.
    Blumenberg C, Barros AJD. Response rate differences between web and alternative data collection methods for public health research: a systematic review of the literature. Int J Public Health 2018;63(6):765–773. Scholar
  51. 51.
    Société Suisse de Médecine Interne Générale. Smarter Medicine - Médecine Interne Générale. 2016.Google Scholar
  52. 52.
    Hasenfuss G, Marker-Hermann E, Hallek M, Folsch UR. [Choosing wisely in internal medicine]. Internist (Berl) 2016;57(6):521–526. Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Nathan Peiffer-Smadja
    • 1
    • 2
    Email author
  • Adeline Bauvois
    • 1
    • 2
  • Marie Chilles
    • 1
  • Baptiste Gramont
    • 1
  • Redwan Maatoug
    • 1
  • Marie Bismut
    • 1
  • Camille Thorey
    • 1
  • Eric Oziol
    • 3
  • Thomas Hanslik
    • 3
  1. 1.Junior Internist AssociationAmicale des Jeunes Internistes (AJI)ParisFrance
  2. 2.Assistance Publique – Hôpitaux de ParisHôpital Bichat-Claude BernardParisFrance
  3. 3.French National Society of Internal MedicineSociété Nationale Française de Médecine Interne (SNFMI)ParisFrance

Personalised recommendations