Choosing Wisely: Grounded in Physician Professionalism
According to the Institute of Medicine report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, as much as $750 billion—or 30 percent [1]—of health care expenditures may be wasted, including a substantial share from services that are not necessary or appropriate.
As physicians, it is our ethical and professional responsibility to make sure that our patients get only the care that is needed and provides benefit. But, often, physicians say they have difficulty saying no to patients’ requests for tests or treatments. Research by Eric Campbell at the Mongan Institute for Health Policy found that more than one-third of physicians said they would accommodate a patient who badly wanted a test, even if the physician knew it was unnecessary. [2]
To help physicians and patients have informed conversations about avoiding unnecessary tests and treatments, the American Board of Internal Medicine (ABIM) Foundation, heeding the words of ethicist Howard Brody [3] and the leadership of the National Physicians Alliance, [4] created the Choosing Wisely campaign.
This effort launched in April 2012, as the ABIM Foundation, Consumer Reports, and nine courageous specialty societies released the first lists of tests and procedures that physicians and patients should question. The 135 items on those lists, backed by evidence and clinical guidelines, were intended to start a national conversation about eliminating waste and unnecessary tests and procedures that don’t benefit the patient, and can even cause harm.
In addition to a press conference and coverage in every major media outlet in the United States, as well as many abroad, more than 100,000 physicians and patients visited www.choosingwisely.org in just 72 hours; a number that has since grown to more than half a million in a year. Clearly, there is both consumer and physician interest in understanding how to have conversations regarding the risks and value of different tests and treatments.
The drumbeat of press coverage continued throughout the year in newspapers, blogs, and meetings. Since the campaign was launched, more than 100 peer-reviewed medical journal articles have cited Choosing Wisely, including many that have published the societies’ full lists of unnecessary procedures. In February, 17 additional societies announced new lists, with at least 20 more planned for later in 2013. All told, more than 40 specialty societies are partners in the Choosing Wisely campaign and are actively communicating with their members about how to engage patients in conversations around the case-specific necessity of certain tests and procedures.
Although we are certainly impressed by this response, I think what is most gratifying is that we have helped stimulate a conversation free of rhetoric or claims of rationing. Rationing is about denying care that is needed; Choosing Wisely is about protecting patients from tests or procedures they don’t need.
To help advance these conversations, and address Campbell’s findings, the ABIM Foundation worked with Drexel University College of Medicine and a number of the specialty societies participating in Choosing Wisely to develop a set of interactive instructional video modules to enhance physician and patient communication. Those modules are being completed now and societies are beginning to share them with their members.
We also recognize that physicians are being asked to manage expensive resources, but that traditional medical training offers few opportunities to learn how to deliver the highest-quality care at the lowest possible cost. To help address this gap in medical education, the ABIM Foundation and Costs of Care recently launched the Teaching Value and Choosing Wisely Competition to identify the most promising innovations and bright ideas that can be successfully implemented on a larger scale. Results of this project will be announced in November.
The foundation also is working to educate physicians in local communities about Choosing Wisely and the societies’ recommendations. Thanks to support from the Robert Wood Johnson Foundation, the ABIM Foundation recently awarded grants to a mix of 21 specialty societies, state medical societies, and regional health collaboratives. Over the next 2 years, these organizations will work at the state and regional level to raise awareness about the Choosing Wisely recommendations and help physicians and patients engage in conversations aimed at reducing unnecessary tests and procedures.
Bringing physicians and patients together to talk about what care is necessary and what care provides little or no benefit—and doing so in a way that is free of rhetoric that stokes irrational fears—is the goal of Choosing Wisely, and is truly professionalism in action.
For more information, visit http://www.choosingwisely.org.
References
- Institute of Medicine. 2013. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press. https://doi.org/10.17226/13444.
- Campbell, E. G., S. Regan, R. L. Gruen, T. G. Ferris, R. S. Rao, P. D. Cleary, and D. Blumenthal. 2007. Professionalism in medicine: Results of a national survey of physicians. Annals of Internal Medicine 147(11):795-803. https://doi.org/10.7326/0003-4819-147-11-200712040-00012
- Brody, H. 2009. Medicine’s ethical responsibility for health care reform—the top five list. New England Journal of Medicine 362:283-285. https://doi.org/10.1056/NEJMp0911423
- The Good Stewardship Working Group. 2011. The “top 5” lists in primary care: Meeting the responsibility of professionalism. Archives of Internal Medicine 171(15):1385-1390. https://doi.org/10.1001/archinternmed.2011.231
