Choosing Wisely: Up Close and Personal February 19, 2013 San Francisco Medicine ABIM, Catherine Lucey, overused medical treatments, ABIM Foundation, Choosing Wisely, overused tests 0 This article was originally published in the January/February 2013 issue of San Francisco Medicine. By Catherine Lucey, MD, FACP A few years ago, I received that phone call that every parent dreads: While riding his bike to school, my teenage son had been hit by a car. Arriving on the scene, I found my son being loaded into an ambulance, strapped onto a backboard, awake, moving all extremities, and apologizing profusely for having been hit. Off to the side was the mangled bike, with the expensive helmet strapped carefully to the handlebars (so much for years of nagging). At the emergency room, a trusted physician colleague carefully listened to the story, asked key questions (no loss of consciousness, no neurologic symptoms), examined my son, and told me that everything looked good. “But you’ll get a CT scan just in case, right?” I asked. He replied no, that the guidelines on scanning in young people recommended against scans in cases like this. To which I responded, “But this is my son! I couldn’t bear it if something was wrong and we missed it.” When I first heard about the idea for the Choosing Wisely campaign, this experience came to mind. Encounters like this happen every day in doctor’s offices and emergency departments across the country. Worried patients bring their concerns to their trusted physicians and ask them to use all that medical science has to offer to reassure them. Those physicians also worry about the patient, often turning to tests and therapeutic trials to be certain that the most dreaded cause of the symptom in front of them is not present. The genesis of this instinct to test early and often and embrace the (deceptively) benign therapeutic trial of an antibiotic, a prescription pain reliever, or a course of corticosteroids or other drugs has roots within our collective support of the professionalism values of prudence (do no harm), excellence, and altruism. This instinct is often reinforced by grateful patients who believe that more care is better care and by powerful anecdotes about physicians who do less and suffer the consequences in courts of law. Although the risk and cost of “probably nothing wrong but to be sure” (PNW) tests seems minimal at first blush, this is often not the case. All of us have had the experience of ordering a test “just to be sure” and getting a false positive result that then generates many more diagnostic studies. The tests that follow are often more invasive and more risky. And some of those benign therapeutic trials result in drug side effects that can range from annoying diarrhea to life-threatening anaphylaxis or other serious adverse consequences. What's more, the financial impact to the patient of PNW tests is difficult to ascertain. The easy-to-order MRI scan for chronic headaches may lead to substantial out-of-pocket costs for the patient with less than comprehensive health insurance. On a larger scale, these tests and treatments contribute to the rapidly expanding costs of health care nationally. As much as a 30 percent of the nation’s 2.7 trillion dollar expenditures on health care may be due to waste, with waste due to overuse of tests and treatment equaling the waste related to administrative complexity.1 The Choosing Wisely Campaign has its origins in Howard Brody’s 2010 New England Journal of Medicine article, in which he called upon each medical specialty society to appoint a blue-ribbon panel to identify the five most frequently used medical tests or treatments that current evidence suggests do not provide benefit for most patients for whom they are ordered.2 Subsequently, the National Physicians Alliance (NPA), supported by a grant from the ABIM Foundation, launched the Good Stewardship Working Group and created “top 5” lists in internal medicine, family medicine, and pediatrics. Research published in Archives of Internal Medicine estimated that cutting back on the tests in the top five lists in primary care alone would lead to savings on the order of $5 billion per year.3 In 2011, building on the work of NPA, the ABIM Foundation recruited nine additional physician organizations to create lists of tests and treatments that are at times overused by physicians in their specialties. The campaign was carefully constructed to reinforce the trusted role of physicians in society. Physicians (not administrators or payors), embracing the professionalism values of excellence and prudence, used scientific evidence to develop lists of tests and treatments that are often given to patients unlikely to benefit from them. Using these lists, the ABIM Foundation launched the Choosing Wisely campaign in April 2012. The campaign reinforces the shared decision making that underpins successful doctor-patient relationships. It encourages physicians to discuss the limitations and risks of the tests and treatments on the list with their patients and help them understand the problems of overtesting and overtreatment. Careful focus on the importance of conversations has helped differentiate the Choosing Wisely campaign, which encourages physicians and patients to talk about tests that do not help and can sometimes cause harm, from rationing, where needed care is restricted to save costs. The campaign also recognizes that changing the culture of U.S. health care—from one in which “more” care is better to one in which “right” care is better—requires addressing public expectations. The work on Choosing Wisely is not done yet, however. Developing and disseminating the lists is a starting point. The important work must be done by physicians in the exam room, in the emergency room, and on hospital wards. Campbell and colleagues remind us how difficult it is to say no to a patient who requests a test that is of no or marginal benefit. In a 2011 study of physicians across the country, they documented that more than one-third of physicians would accommodate a patient who asked for a test even if that test was not indicated.4 The frequently used argument that patient autonomy demands that physicians acquiesce is a misuse of the concept of autonomy and ignores our commitment to excellence and prudence.5 Next steps in this work include formulating strategies to help physicians in practice and physicians in training master the skills necessary to communicate the risk of unnecessary tests and treatment and to offer other forms of reassurance to worried patients. Medical students and residents need to learn when to watch and wait rather than prescribe unnecessary tests and treatments. It is also critically important to support physician decision making that uses the tests and treatments on the lists when they are indicated. More outreach to community organizations, patient advocacy groups, and educators responsible for health education in our schools will lead to patients who are willing to engage with us in meaningful conversations that focus on getting the right care at the right time. And what about my son? The physician took me aside, explained that new studies have documented the risks of radiation on growing brains, and showed me the practice guidelines that outlined when CT scans were indicated following accidents. He then reassured me that I could call him personally if new symptoms emerged. All in all, it took more time, empathy, and skill than simply ordering the CT scan – and considering I was a physician myself, it also took a certain amount of courage. But our conversation gave me confidence that the decision not to test was based on our doctor’s willingness to put my son’s best interests at the forefront of his decision-making process – the true definition of professionalism. All is well. Click here for more information about the Choosing Wisely campaign and partnering organizations. Click here to access the January/February 2013 issue of San Francisco Medicine focusing on the Choosing Wisely campaign and perspectives from physicians of different specialties about reducing waste in medicine. Medical Professionalism Project. Medical professionalism in the new millenium: A physician charter. Ann Intern Med. 2002; 136(3): 243-246. Brody H. Medicine’s ethical responsibility for health care reform—The top five list. New Engl J Med. 2010; 362:283-285. The Good Stewardship Working Group. The top five lists in primary care: Meeting the responsibilities of professionalism. Arch Intern Med. 2011; 171(20):1858-1859. Campbell EG et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007; 147:795-802. Emanuel EJ, Pearson SG. Physician autonomy and health care reform. JAMA. 2012; 307 (4): 367-368. Comments are closed.
