Campaign pushes doctors to be the best
"YES"
Of all the tools at a physician’s disposal, the pen – and now the mouse – is among the most powerful. In a system that rewards physicians for doing more, it is no surprise that more is done. More tests and more procedures – often leading to more waste and more potential harm to patients.
In the Choosing Wisely campaign, I see professionalism at its highest level, as the campaign calls on physicians to be the very best doctors they can be for their patients. Nearly 60 societies have joined; by early next year, they will have issued more than 300 recommendations of tests and procedures they say are overused or unnecessary, based on the latest research and evidence. While we strive to embody professional values, clearly there are many areas in which we are doing things that do not benefit our patients.
Dr. Richard Baron
Can Choosing Wisely improve quality of care? It already is. Systems are beginning to embed conversations on overuse—the aspiration of the campaign—into their cultures through electronic health records (EHR) and other constructs. For example, Cedars-Sinai Medical Center has incorporated 120 Choosing Wisely recommendations into its EHR system. When a physician orders tests, procedures, or medications that may be unwarranted or pose unnecessary risks, the system alerts the physician and provides information on the relevant Choosing Wisely recommendation.
Inspired by the campaign, Kaiser Permanente conducted an institutional review and has launched projects to reduce overuse of imaging in five areas: for uncomplicated headaches; of carotids for syncope without neurologic symptoms; for low back pain; for adnexal cysts; and for pulmonary embolism with low probability. In those areas, it is performing chart reviews to determine how widespread overuse really is. In the case of imaging for uncomplicated headaches, Kaiser Permanente found that 25% of employed physicians’ orders were unnecessary.
These are just two examples, and we are hearing many more as additional organizations join the effort and the ABIM Foundation’s 22 grantees advance projects in their communities.
There are some critics that say the campaign should address liability or tort reform. Those criticisms are misdirected—that’s not what Choosing Wisely is about. It is about conversations between physicians and patients aimed at getting the best care possible.
Choosing Wisely will help improve quality of care because it allows us – physicians and patients together – to find common ground by identifying areas in which we can avoid harm and helping change the mindset "more is better."
Reducing waste and improving care is complicated, but I am optimistic we are headed in the right direction. Physician leadership exemplified by Choosing Wisely has created spaces for us to have productive conversations about how we can work together to provide better care to all.
Dr. Richard Baron is the president and CEO of the ABIM Foundation, which spearheads the "Choosing Wisely" campaign.
Campaign lacks standard for ‘unnecessary’
"NO"
The Choosing Wisely campaign has the noble intent of trying to improve the quality of medical care in this country by decreasing the amount of unnecessary testing being performed. Many Choosing Wisely recommendations appear reasonable, yet many other recommendations may decrease the quality of medical care while increasing legal liability.
Perhaps the biggest flaw in the Choosing Wisely initiative is a lack of uniform metrics. It is easy to assert that a test is unnecessary, but what criteria are used to reliably and prospectively define what is necessary? Cost basis? Sensitivity? Negative predictive value? Failing to have a standard definition for "unnecessary" medical care invites hindsight bias into the determination of a test’s utility. Similarly, it is disingenuous to assert that Choosing Wisely will enhance the quality of medical care without first defining and vetting specific quality benchmarks. How can we improve quality when we haven’t even defined quality?
Dr. William P. Sullivan
While some Choosing Wisely recommendations have a clear benefit (antibiotics just won’t cure children’s coughs), clinicians who follow other Choosing Wisely recommendations will inevitably miss more heart attacks, more pulmonary emboli, and more treatable cancers. Of course, the number of diagnostic misses will amount to only a small percentage of patients who would have otherwise received the unnecessary testing, but with more than 1 billion yearly outpatient medical visits in this country, that small percentage may total tens of thousands of patients with potential adverse outcomes caused by following Choosing Wisely recommendations.
According to the Institute of Medicine, up to 98,000 patients die from avoidable medical errors each year. Missed diagnoses account not only for a substantial portion of those avoidable deaths but are also the most common cause of malpractice litigation in the United States. Rest assured that when a physician withholds testing to decrease government expenditures, few state medical boards, fewer juries, and no patients will deem it "quality" medical care when a diagnosis is missed. We won’t convince the public that a preventable death from an undiagnosed pulmonary embolism resulted from adherence to a "quality" initiative. When bad outcomes occur, patients won’t thank us for being stewards of medical resources.