Choosing Wisely: Doctors Want To Do The Right Thing @muirgray @drsilenzi

June 6th, 2012 

Getting physicians and patients talking about whether tests are necessary is a small but important first step in addressing what is wrong with our current health care system.  Issues such as how we pay for care, how we organize our delivery systems, and how we engage and empower patients in their own care choices all must be addressed.  But for any change to be successful, we need a real partnership between doctors and patients.

Doctors want to practice medicine based on the best available evidence.  They want to have time to talk with patients and their families.  This is the essence of medical professionalism and it is the first step to achieving real change in the way we deliver health care.

That is why I am heartened by the physician response to the Choosing Wisely campaign, a project of the ABIM Foundation, medical specialty societies and Consumer Reports. At the heart of the campaign are a series of lists of tests and procedures to question – developed by the societies.  Each society came up with a list within their domain of practice.

In releasing the lists we were asked time and again by reporters:  Why would physicians develop lists of overused tests and treatments?  Doesn’t this hurt their own bottom line?  The reporters all seemed skeptical and surprised.  As a physician, I was not at all surprised.  At the heart of medicine is the obligation to do what is in the best interest of our patients, not what is in the best interest of our pocketbooks.

A Positive Physician Response

The initial nine societies that joined Choosing Wisely (reaching more than 370,000 physicians) report that they have received relatively few negative comments and a large number of positive comments from their physician members and from physician and other healthcare professionals in the blogosphere:

From cardiologist John Mandrola: “That our thought leaders are now proclaiming–and social media is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.”

Internist Eric Larson noted: “The Choosing Wisely initiative is remarkable because doctors’ professional advocacy groups are making recommendations that are often counter to their own economic interests.  By recognizing elimination of unnecessary care as a matter of professional ethics, medical professionals in a broad range of specialties may be signaling that we’re reaching a tipping point toward solving America’s health care cost crisis.”

Dr. James Salwitz: “At its base, the Choosing Wisely Campaign is simple.  What is the data?  What really helps?  What hurts?  How can we work together to educate everyone about the best care?  However, the concept of making decisions in this way is revolutionary.  Without government or insurance control, it gives information so that patients and physicians can together make quality personal decisions, while maintaining medical freedom.  With this kind of initiative, we, the patients, the doctors, the people, can seize control of health care in this new Century.”

Even other health professionals understood the implications of this effort, Megan Kilpatrick, an oncology nurse, blogged the following: “Called the “Choos­ing Wisely Ini­tia­tive,” this coali­tion aims to edu­cate com­mu­nity physi­cians by encour­ag­ing nec­es­sary and evidence-based prac­tice. Now, before you get up in arms, cry­ing foul about health­care rationing, under­stand that this ini­tia­tive is not about lim­it­ing access to health care but rather assist­ing physi­cians in pro­vid­ing appro­pri­ate health care. The ini­tia­tive aims to pre­vent harm and dupli­ca­tion of pro­ce­dures and encour­age health care that is not sup­ported by evi­dence and truly necessary.”

While they were in the minority, some of the negative reactions were not surprising.  Physicians raised concerns about defensive medicine (and the need for tort reform to reduce it) and the impact of these recommendations on physicians’ income.  When confronted with negative feedback, the medical societies defended their involvement in the campaign and responded in a thoughtful way about the importance of protecting patients from the risks of medical interventions, reducing waste in health care and engaging in responsible stewardship of medical resources.

For example, when members of the American College of Cardiology (ACC) made critical comments about the ACC’s participation on its website, the society took them head on.  Dr. Manuel D. Cerqueira, Chair of the ACC’s Imaging Committee, wrote: “In no way were the Choose [sic] Wisely recommendations made to insinuate cardiologists are unethical, but at the same time cardiologists can’t deny there is overuse of medical resources.  By participating in the program we are hoping to foster better patient-physician discussions on testing and care, and to drive testing decisions in the direction of doing something because we should, not simply because we can.”

Evidence-Based Recommendations Developed By Physicians, For Physicians

The medical societies were able to defend their participation in Choosing Wisely because their recommendations were based on rigorous evidence, with most of them coming from existing guidelines the societies had developed.  Indeed, this campaign promotes recommendations developed by physicians, based on evidence, and delivered to physicians.

Choosing Wisely focuses on what is best for patients: reducing waste and reducing harm.  In doing so we expect that the effort could yield significant savings to the health care system – some estimate that 3 in 10 dollars spent on care is on unnecessary care. However, the rhetoric of our political system has made it risky for leaders to express concern about health care costs, since anyone who calls for reductions in health care spending—no matter how wasteful—may immediately be accused of rationing.

That’s what makes this effort by the profession “a game changer,” as noted by Don Berwick.  Physicians, many of whom may stand to lose some income by reducing unnecessary tests, know that it is the right thing to do.  Indeed, I’ve had a sense in the last few weeks that there is a collective “sigh of relief” among the physician community that we are now getting serious about reducing waste in our health care system in order to sustain the promise of expanded coverage and better access to effective medical care for many more people in this country.  As one physician commented on the ABIM Foundation’s blog, “The public expects more of the physician community than for us to protect the status quo for the sake of our pocketbooks or convenience.”

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