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



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.


Scientific and technological advances in the medical field have led to the development of new diagnostic procedures and new therapeutic options. Although this process is generally beneficial and desirable, it has also led to the emergence of medical situations of overdiagnosis or overtreatment. These situations can lead to adverse effects for patients and significant additional costs in healthcare and there is now a need of “de-implement” or phase out interventions that are not supported by evidence.1 Overmedicalization has been gaining international momentum, as shown in the “Less is more” columns of the JAMA Internal Medicine.2 or “Too much medicine” of the British Medical Journal.3 The American Board of Internal Medicine launched in 2012 a national project named “Choosing Wisely” which aims to encourage health professionals and patients to engage in dialogue about unnecessary and potentially harmful diagnosis procedures and treatments.4, 5 It was proposed to every American scientific society to create a list called “Five things that doctors and patients should question” sometimes referred to as Top-5 list. This initiative spread rapidly in Canada, Australia, the UK, and Japan.6,7,8

In 2016, the EFIM (European Federation of Internal Medicine), which brings together the national societies of internal medicine and represents over 40,000 internists in Europe, decided to encourage European internal medicine societies to participate in “Choosing Wisely.” This call has been relayed by the French Hospital Federation (FHF), a public organization which promotes, informs, and represents public hospitals and medico-social institutions in France. The FHF asked in 2016 each French scientific society to define a Top-5 list. Subsequently, the French National Society of Internal Medicine (SNFMI) created a working group dedicated to this task. The SNFMI is the French leading and only national society in Internal Medicine. It represents internists whatever their professional status, working place, practice, or region in every political and public health instance. French Medical Board 2016 data shows that 2219 internists are registered in France and the SNFMI counts 1491 members; thus, we can consider that around 67% of the total French internists are registered with the SNFMI.9 It includes the Junior Internist Association (AJI), which is the only national group of internal medicine residents. It is important to note that French internal medicine residency is a separate specialty that encompasses clinical immunology and general internal medicine. The 5-year residency needed for this specialty is not the core curriculum for other specializations. Another characteristic of internal medicine in France is that more than 90% of French internists practice in the public system as reported by the French Medical Board.9

In this article, we present the result of the SNFMI national survey to define the Top-5 list in internal medicine.


Working Group

A working group (WG) of 15 members (7 women and 8 men) was set up in January 2017; it included 9 members of the SNFMI (7 professors or assistant professors and 2 hospital practitioners) and 6 members of the AJI (5 residents and 1 fellow). Three members of the working group worked in a general hospital and the 12 others in academic hospitals.

Phase 1: Selection of Medical Procedures

In 2017, each member of the WG reviewed the Top-5 lists of Australian, American, English, and Canadian societies of internal medicine, hospital medicine, vascular medicine, rheumatology, infectious diseases, general medicine, geriatrics, and clinical immunology. The members were also encouraged to add procedures from personal experience or other Top-5 lists. Each member selected up to 15 procedures that seemed frequent, unhelpful, potentially risky, and based on no scientific evidence. Then, each procedure was reviewed and discussed by the WG during teleconferences, in order to eliminate duplicate procedures and those that did not reach consensus. For each selected procedure, at least two different members of the WG searched literature for scientific evidence.

Phase 2: National Survey of Internists

A call for participation was sent by email to all members of the SNFMI and the AJI. Each volunteer had to respond to the email in order to receive a personal link of participation, automatically generated and linked to a unique identifier. The support of the survey was a website that provided access to the questionnaire and the list of the medical procedures selected in phase 1 (each accompanied by at least three and up to ten relevant bibliographic references). The first part of the questionnaire collected demographic information and the second part of the questionnaire allowed for an evaluation of each procedure with a numeric scale using a score between 1 and 5 for its perceived frequency, uselessness, and risk. The order of appearance of medical procedures was random for each participant to avoid bias due to changes in the participant’s way of rating medical procedures during the questionnaire (e.g., modification of the concentration level).

Statistical Analysis

Data were entered into a spreadsheet and imported into R software (version 3.2.4) for statistical analysis. For each procedure, a composite score was calculated as an unweighted addition of the three scores of frequency, risk, and uselessness. This composite score was used to define the final Top-5 list. Numerical data are presented as absolute numbers, proportion, mean ± standard deviation (SD), or median ± interquartile range (IQR). We used Pearson’s chi-squared test for categorical variables to compare the demographic characteristics of our sample of participants with the population of the SNFMI and AJI. We calculated correlations between the scores using Spearman rank-order correlation coefficient (rs). We used the free R package “FactoMineR” to draw a circle of correlation.


Phase 1: Selection of Medical Procedures

A total of 123 medical procedures from 20 Australian, American, British, or Canadian scientific societies were systematically reviewed by each member of the WG. The selection of members of the WG resulted in a list of 49 medical procedures. After subsequent meetings, a list of 27 medical procedures that were agreed upon in the WG was retained (Fig. 1). Four medical procedures came from the personal experience of members of the WG. Table 1 presents these medical procedures and specifies for each item its presence or not in existing Top-5 lists.

Fig. 1

Steps for the selection of the medical procedures.

Table 1 List of the 27 Medical Procedures Selected During the First Phase and Evaluated in the National Survey

Phase 2: National Survey of Internists

Among the participants 59% were men (n = 255) and the median age was 35 years (IQR, 28–43 years) (Table 2). All French regions, including ultramarine regions, were represented. All the status of the profession participated in the survey with 186 residents (44%), 74 fellows (17%), 100 hospital practitioners (23%), 48 professors or university lecturers (11%), and 18 working as independent physicians (4%). Three hundred fifteen (77%) participants worked in university hospitals, 53 (13%) in general public hospitals, 13 (3%) in military hospitals, 20 in private hospitals (5%), and 10 in medical offices (2%).

Table 2 Demographical Characteristics of Participants in the National Survey

For the 27 medical 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 (Fig. 2). Table 3 presents separately the 10 most frequent, the 10 least useful, and the 10 riskiest medical procedures, as reported in the survey.

Fig. 2

Score of frequency, uselessness, and risk of the 27 medical procedures.

Table 3 The 10 Most Frequent, Riskiest, and Least Useful Medical Procedures According to the National Survey of French Internists

The composite score calculated as the unweighted addition of the three scores allowed us to define the French Top-5 list in internal medicine (Table 4):

  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 (VTE) 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

Table 4 The French Top-5 list in Internal Medicine

Sample Representativeness

Table 2 compares the population of the SNFMI including AJI with our sample of participants. There were significant differences between the age breakdown (p < 0.001), the professional status (p = 0.001), and the working place (p < 0.001), reflecting the fact that there was an overrepresentation of young internists, residents, fellows, and physicians working in academic settings.

We repeated our calculations with different groups to determine if these biases could influence the Top-5 list. If we excluded residents (n = 244), the five Top-5 items were exactly the same, the only difference being that the second item ranked third and the third ranked second. If we excluded residents and fellows (n = 170), four of the five Top-5 items were the same, with the replacement of the item on “Lyme test,” ranked 5th, by the item “IV > PO,” ranked 7th. The 10 items that achieved the highest composite score were exactly the same (but in a slightly different order). If we excluded professors or assistant professors (n = 382), four of the five Top-5 items were the same, with the replacement of the fifth item “Lyme test” by the sixth item “Heparin bridging.” Finally, if we excluded internists practicing in university hospitals (n = 115), the five Top-5 items were the same but ranked differently: 1. “Hypnotics,” 2. “Long-term PPI,” 3. “Anticoagulants > 3 months,” 4. “Treatments in dementia,” and 5. “Lyme test.” The 10 items that achieved the highest composite score were exactly the same.

Relations Between the Scores

To determine whether the perceived variables (frequency, uselessness, and risk) were independent, we conducted correlation tests between the three scores. There was no correlation between the frequency and the risk score (r = − 0.17, p = 0.4) nor between the uselessness and the risk score (r = 0.01, p = 0.9) but there was a significant inverse correlation between the frequency and the uselessness score (r = − 0.5, p = 0.008).

To determine which score(s) weighted most in the final ranking of items, we conducted a correlation test between the composite score (used for the Top-5 list) and each of the three scores. There was no correlation between the final score and the frequency score (r = 0.06, p = 0.75) nor between the final score and the uselessness score (r = 0.17, p = 0.38) but there was a strong and significant correlation between the final score and the risk score (r = 0.89, p < 10−5). A circle of correlation summarizing these results is presented in Fig. 3.

Fig. 3

Correlation between the scores and circle of correlation. Legend: left panel: graphical representation of the Spearman’s correlation between the frequency and the uselessness score (top) and between the risk score and the composite score (bottom). Each point represents one of the 27 medical procedures. Right panel: circle of correlation with the scores represented by their correlations. The composite score, which is an unweighted addition of the frequency, risk, and uselessness scores (black arrows), is represented by a red arrow.


The French National Society of Internal Medicine and the Junior Internist Association participated in a national web-based survey to determine a Top-5 list in internal medicine. The five following procedures were selected:

  1. 1.

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

    Proton-pump inhibitors (PPIs) are one of the most prescribed treatments in France and represent a major cost for national health insurance, estimated at one billion per year by French social welfare.10 The main indications for long-term use are recurrent gastroesophageal reflux disease, Barrett’s esophagus, and prevention of gastroduodenal lesions in patients at risk treated with NSAIDs.11 However, it is estimated that a large number of prescriptions (between 25 and 70%) are made in out-of-label clinical situations.12 Moreover, chronic intake of PPIs is associated with an increased risk of malabsorption (vitamin B12, magnesium, calcium, iron), osteoporotic fractures, infections (including Clostridium difficile pseudomembranous colitis), digestive neoplasia, drug interactions, dementia, and renal failure.13 Therefore, regular reassessment of the indication and dosage of long-term PPIs is essential. PPIs are already mentioned in many Top-5 lists (e.g., Italian society of Internal Medicine, Royal Australian College of General Practitioners) and many tools already exist to help physicians deprescribe PPIs.14, 15

  1. 2.

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

    The data supporting the use of preventive treatments in older people is scarce especially in patients suffering from dementia.16 The US Preventive Services Task Force concluded in 2016 that the current evidence is insufficient to assess the balance of benefits and harms of the use of statins in elderly patients.17 Antihypertensive medications have been found to increase the risk of serious fall injuries among community-living adults older than 70 years and the risk even increased among the frailest patients.18 In a recent study assessing more than 500,000 patients’ files, an increase in the number of drugs administered to patients during their last year of life was observed, including drugs for the long-term prevention of chronic diseases.19 Thus, physicians should always take into account the degree of dementia and wonder whether a patient life expectancy is longer than the time needed for the medication to achieve its benefit.20 This proposition does not mean that all preventive treatments should be stopped in older people with dementia but that the potential harms versus benefits of each drug prescribed in this population should be carefully weighed and discussed with the patient and his family.

  2. 3.

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

    Insomnia is a common pathology which can be exacerbated during hospitalization.21, 22 Many practitioners use benzodiazepines and other hypnotics as first-line treatment for insomnia. However, despite the efficacy of hypnotics in insomnia, many studies have shown deleterious effects associated to their use, as an increase in the risk of falls, road accidents, cognitive disorders, and delirium, particularly in the elderly.23,24,25 The therapeutic approach proposed to the patient suffering from insomnia must be multiple, and drugs, toxic, or other risk factors for insomnia should be systematically investigated. Non-pharmacological treatment, such as cognitive-behavioral therapy, should be offered as first-line treatment, as recommended in the latest European and American guidelines.21, 26

  1. 4.

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

    Anticoagulant treatments have been shown to be effective to prevent the risk of thromboembolic recurrence after a proximal deep venous thrombosis (DVT). The optimal duration of anticoagulation rests on the balance between the hemorrhagic risk and the reduction of thromboembolic recurrences. When factors favoring DVT are identified, the risk of recurrence after DVT is almost half as high as when they are absent and the prolongation of anticoagulant treatment is associated with an increase in the number of major bleeding complications.27, 28 These elements support a short duration of treatment for DVT following a major transient risk factor. Treatment of 6 months compared to 3 months in case of provoked DVT does not bring benefits in terms of reduction of recurrence, but increases the hemorrhagic risk by approximately 2.5 times.29 These recommendations do not apply in the case of non-controlled risk factors (including progressive cancers), or in cases of recurrent DVT.29, 30

  1. 5.

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

    The inappropriate use of testing for Lyme disease is frequent and can lead to wasteful health care spending and significant patient harm. Lyme testing has been consistently found to be ordered inappropriately in more than 50% of cases in endemic areas and even more in non-endemic areas.31, 32 In a recent study in the Netherlands, only 9% of the serological testing for Lyme were supported by guidelines.33 Unfortunately, many patients who are inappropriately tested receive antibiotics irrespective of serologic results, resulting in the inappropriate use of antibiotics that may cause severe adverse events in patients.32, 34, 35 Testing for Lyme should only be considered in patients with an appropriate exposure history and objective findings on clinical examination.36 Clinical situations associated with inappropriate use of testing include patients reporting asymptomatic tick bites or patients mentioning nonspecific symptoms such as chronic fatigue or chronic diffuse arthralgias and myalgias, even in endemic areas.32, 37 As it is the case in the USA, Lyme disease has recently become one of the most widely debated medical subjects in France.

This Top-5 list has been endorsed by the SNFMI, the only internal medicine society in France. We relied both on previously published lists but also on the personal experience of each member to propose new medical behaviors. This allowed to consider seven original procedures and evaluate four in the national study. As it has been shown that many Choosing Wisely recommendations are based on expert consensus or disease-oriented evidence,38, 39 we carried out a national web-based survey to reflect the opinion of the French internists. We estimate that with 430 responses, approximately 14% of the total number of internists at work or undergoing training in France responded to this survey. To our knowledge, this Top-5 list in internal medicine has been compiled with one of the highest numbers of participating physicians.40,41,42,43,44,45 Moreover, the fact that 44% of participants were residents is original and encouraging. Given that today’s residents will be the prescribers of tomorrow, it seems important to raise early awareness of the problem of overmedicalization.

The use of a composite score is original and, to our knowledge, has not been used in previous Top-5 lists. This allowed us to study the relationship between the perceived frequency, uselessness, and risk score for each time. We found a significant inverse correlation between frequency and uselessness scores in this study. This could be interpreted as the fact that the more a practice was perceived as useless the less it was perceived as frequent. On the contrary, the risk score in our study was not correlated to the uselessness and frequency scores. Using correlation tests, we found that the composite score, which is a simple addition of the frequency, risk, and uselessness score, was strongly correlated only to the risk score. Thus, the evaluation of the perceived risk was the most relevant in our study and could suggest that the risk score is the most important when elaborating a Top-5 list.

This study has several limitations. First of all, we did not involve the patients’ point of view during this survey. Yet, choosing wisely aims to select practices that should lead to a discussion between physicians and patients.46 Involving patients could help raise awareness of the issues and risks of overmedicalization.38, 47 Further work will need to consider co-design Top-5 lists with patients.48 Another limitation is the high attrition rate despite our work to engage French internists in the survey. This is a common caveat of web-based surveys, especially when addressing a large population, and should be considered when planning Top-5 lists based on an internet questionnaire.49, 50 Another concern was the risk of bias due to the high proportion of residents and the high proportion of physicians working in university hospitals and academic physicians among the participants. However, subsequent statistical analyses showed that the final Top-5 list would have been the same or shared 4 items out of 5 when varying the population. Finally, it should be noted that Top-5 lists are not intended to eliminate the use of the selected procedures. They only encourage physicians and patients to discuss their use and this may be particularly relevant for the second procedure of this Top-5 lists addressing the prescription in older people with dementia.

This list was produced as part of an EFIM initiative and joins other European lists published in internal medicine in Italy, Switzerland, and Germany.41, 51, 52 Next steps will have to focus on the ways to implement this Top-5 list and to evaluate its impact, including potentially negative consequences. Physicians need to be challenged to question their practices and the results of our study could be the starting point of French national communication campaigns.


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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.

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Correspondence to Nathan Peiffer-Smadja MD, MS.

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Peiffer-Smadja, N., Bauvois, A., Chilles, M. et al. The French Society of Internal Medicine’s Top-5 List of Recommendations: a National Web-Based Survey. J GEN INTERN MED 34, 1475–1485 (2019).

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  • Choosing Wisely
  • overmedicalization
  • internal medicine
  • inappropriate prescribing