Tuesday, October 14, 2014

Choosing Wisely – Created By Physicians For Physicians

By Elizabeth Torres, MD
President, Harris County Medical Society

This article originally appeared on the President's Page of the Harris County Medical Society's Physician Newsletter.

As physicians we know that sometimes the most difficult part of our profession is managing patient expectations. Those expectations often come from advertising, newspaper articles or the television news, promising that new treatments and diagnostic tests are available. So patients, having diagnosed themselves with the help of friends or internet site questionnaires, come armed to their office visit with this new information to share and expect to receive certain tests, treatments and/or prescriptions. We often feel compelled to accommodate these requests, knowing that sometimes the testing or treatments are not necessary, could be harmful and costly, and certainly will not change the outcome of their care. We also know that we cannot diagnose all illnesses with certainty, which is what patients really want. Our listening skills and physical exam are our best diagnostic tools. Symptomatic treatment and watchful waiting is all that is needed in many cases. Indeed, we do see patients that require specific testing/treatments that they may not like, and we must justify the need for such testing as well. Additionally, discussion with our patients about the need for certain tests or treatments can be challenging for us and may be disappointing for our patients if we don’t take the time necessary for them. Patients may lack the knowledge and/or understanding to fully comprehend the situation, and it’s sometimes difficult to fully communicate the scientific background behind our reasoning. The Choosing Wisely® campaign is an initiative that was started by the American Board of Internal Medicine (ABIM) Foundation that aims to help physicians begin these conversations. It now includes more than 60 specialty organizations.

Our current health care delivery system does too little to coordinate care for patients with chronic conditions and the government and payers are requiring physicians to invest in expensive health information technology (HIT) without ensuring that the investment translates into better patient care. Additionally, the government imposed metrics to measure effectiveness and efficiency are often off-target. For physicians, the way to save money is not through rationing of care but to ensure the right professionals provide the right care, at the right time and place. Therefore, the responsibility to coordinate patient care falls to physicians.

Choosing Wisely is physician created, physician driven, and physician supported. The goal of the national campaign is to improve quality and reduce waste by having physicians and patients talk about medical tests and procedures that may be unnecessary and possibly harmful.

In 2010, Howard Brody, MD, University of Texas Medical Branch Institute for the Medical Humanities, published an article in the New England Journal of Medicine challenging the medical profession to lead the charge in defining quality care and reducing waste in the health care system. This article served as the catalyst for what is now the Choosing Wisely campaign. Recognizing that each physician specialty is unique in what it considers low value tests and procedures, the campaign challenges every specialty to develop its own list of five diagnostic tests that are overused and potentially harmful to their patients. We need to explain to patients that our differential diagnosis is based on their history and physical exam. We also need to explain why certain tests or treatments will be needed and discuss our plan of action. This removes the shroud of mystery or lack of understanding that patients feel when they leave the office and their family asks “What did the Doctor say?” The Choosing Wisely program also provides help by including handouts for patients on its website.

Participating medical specialty societies range from the American College of Physicians, the American Academy of Neurology to the American College of Surgeons. Each specialty creates its own top five tests or procedures. For example, the American College of Physicians recommends to not obtain imaging studies in patients with non-specific low back pain. Separately, the American College of Surgeons recommends avoiding routine use of whole-body diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

These lists provide support to physicians by allowing our patients to see that our recommendation came from a consensus of national expertise. However, each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together. Choosing Wisely should never be used to establish coverage decisions or exclusions nor interrupt the patient-physician relationship. This is a tool to help us talk with patients when it comes to choosing any test or treatment for them.

With the passage of Tort Reform in Texas, defensive medicine does not have to get in the way of talking to the insistent patient about not needing that antibiotic, CT scan, or other procedure. One of the most common discussions we have with patients concerns giving antibiotics. As we all know, antibiotic resistance is getting to crisis levels in the U.S. from overuse, fostering the emergence of drug-resistant germs. In September 2013, the Centers for Disease Control and Prevention issued the first solid numbers on the extent of the problem. It said that at least two million Americans fall ill from antibiotic-resistant infections each year, of whom at least 23,000 die from the infections. It is up to physicians to reduce the use of antibiotics, when there is evidence to show lack of effectiveness and real risk of harm.

In the current health care environment, every health care entity is looking at ways to increase efficiency and reduce cost. We physicians, by virtue of our daily practice and scientific literature, know which procedures and tests are valuable and which are not. To protect the safety of our patients, we must be stewards of quality initiatives and lead instead of follow.  Engaging patients in these types of discussions will improve communication and understanding with our patients and should lead to better outcomes and patient satisfaction as well.

If you would like to learn more about the Choosing Wisely campaign, go to the Texas Medical Association website at www.texmed.org/choosingwisely/ or take a continuing medical education (CME) webinars (free for a limited time) for 3.75 ethics credit by going to www.texmed.org/ChoosingWiselyCME.

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