'Choosing Wisely' Praised and Sometimes Feared
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Friday, November 03, 2017 07:37 AM

The “Choosing Wisely” initiative has done a lot to change the culture around performing unnecessary procedures. In 2012, the American Board of Internal Medicine (ABIM) debuted “Choosing Wisely," asking specialty groups to produce a list of five tests or procedures that may be overutilized. 

There were four rules that the groups had to follow:

  • It needed to be in their discipline
  • It needed to have an impact -- that is, it had to be a test or procedure that was very expensive or performed a lot
  • It needed to have evidence that it was being done too much
  • There needed to be a transparent process for choosing each item

Five years later 80 medical societies have lent their intellectual capital to thinking about this.

Often, what patients really want is reassurance, said Arthur Hong, an assistant professor at the University of Texas Southwestern Medical Center in Dallas. "I was seeing a patient who had come in for acute back pain; a few minutes in, he lets it slip that he's a radiologist," Hong said. "He says, 'I know the evidence on imaging shows it doesn't improve pain' -- [I figured out that] this guy's asking me if he can have imaging for his back pain. He's in such excruciating pain that he just wants something done."

Instead, Hong approached him like a regular patient, saying, “Here's why we do imaging and here's what reassures me that you don't need it; if anything changes, we can change our management" of your case. That approach worked well, Hong said.

Two common objections Hong hears when people talk about reducing unnecessary imaging are "the malpractice boogeyman and the idea that patients demand imaging, which is its own feedback loop. We need to talk to patients about how it's not that more care is better, but that the right care is the best."

The founder and executive director of a consulting group aimed at helping health systems provide quality care at lower cost, said that "health systems are set up where patients can be hurt in two ways: when we do too little, too late, and when we do too much, too soon." For a long time, "there were blind spots" to the latter problem, he said.

“Every case conference we had [during medical training] was about things that were exceedingly rare, and we reward people for findings things that are exceedingly rare. We'd be chastised for not doing the things we could have done, but never for doing something we didn't have to do."

In the end, “the big force driving health policy in this country … turns out to be about money."

Source: https://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/68769