In Montana, the belief that America is a nation with no limits courses through the state’s Big Sky culture. That’s why Bozeman cardiologist Dr. John Erb understands that it can cut against the grain to suggest that more health care isn’t always better. However, a national campaign to encourage appropriate treatment, dubbed “Choosing Wisely,” has helped Erb successfully undertake the delicate procedure of identifying and addressing overtreatment.
The Choosing Wisely effort encourages participating medical societies to each identify five tests and procedures that are often used unnecessarily and that could possibly cause harm. Broken down by specialty, each of these lists, titled Five Things Physicians and Patients Should Question, is backed by evidence underlying the selections. Developed by the ABIM (American Board of Internal Medicine) Foundation under the leadership of Dr. Christine K. Cassel, the goal is to spur doctors and patients to talk more about when it’s right to do less.
If you could scale up one remarkable health care idea, what would it be?
"We can improve health care by encouraging a real patient-physician partnership. The Choosing Wisely program is helping by promoting conversations about evidence-based information concerning potentially overused tests or treatments. Armed with clearly understandable information from trusted sources, patients and physicians can make personalized decisions and reduce waste and harm."
- Christine K. Cassel, President and CEO of the National Quality Forum and former President and CEO of the American Board of Internal Medicine
In an interview posted on the campaign organizers’ website, Erb explained that because the campaign is “all based on data and evidence…it simplified my approach in telling folks they don’t need certain things.” Erb, who practices at Bozeman’s Deaconess Health Group, continued, “If I tell them they don’t need something and there’s no evidence it will help them, 99 percent of patients accept it with no questions asked. They say, ‘If I don’t need it, I don’t want it.’”
As for fellow doctors who might be skeptical, the Choosing Wisely lists come from “their own kind” in their own specialty. That, says Erb, a trustee of the American College of Cardiology, “makes it difficult to ignore.”
Choosing Wisely arose out of an ethical challenge. Writing in the New England Journal of Medicine in early 2010, Dr. Howard Brody criticized medical groups for being bystanders in the fight to control rising health care costs. He asked each specialty to come up with a “top five” list of tests and treatments that could be eliminated without depriving patients of “meaningful medical benefit.”
Dr. Christine K. Cassel, president of the ABIM, was intrigued. “People kept calling on the profession to do the right thing,” remembers Cassel, who has since become president and CEO of the National Quality Forum. “There were ways we were contributing to waste, and we could do better in reducing it.”
The ABIM Foundation gave a grant to the National Physicians Alliance to turn Brody’s idea into reality. Their charge was to work with groups representing internists, family practice physicians (Brody’s specialty) and pediatricians to develop a list of 15 overused procedures. Encouraged by the initial results published in 2011, the foundation broadened its coalition to include nine societies and asked Consumer Reports to prepare patient-oriented communication materials that would help make patients real partners. A press conference in April 2012 identified 45 overused tests and procedures. They ranged from routine chest X-rays before surgery to brain imaging scans after fainting. It drew instant national publicity.
Cassel knows the timing was fortuitous. “We were in the middle of a fiscal crisis, and everybody was beginning now to talk about health care costs,” she says. An Institute of Medicine roundtable, for instance, estimated that a staggering $210 billion in unnecessary medical services are provided every year.
Adds Cassel, “It all came together at a time when people were looking for a message that wasn’t about rationing and big bad insurance companies and government, but was about what makes sense for me, the patient.”
In just a little over a year, the campaign has mushroomed. It has now been joined by 59 medical societies whose members total about 500,000 physicians, or more than 60 percent of all practicing physicians. Of those groups, 44 have already released lists of often unnecessary and possibly harmful tests and procedures. Three groups have released two lists, and one, the American Academy of Family Practice, has issued three. Kaiser Permanente and Intermountain Healthcare have incorporated the guidelines into electronic medical records, effectively transforming them into clinical decision tools.
The consumer outreach effort has been equally comprehensive. Consumer Reports developed materials to explain many of the recommendations in patient-friendly language, encouraging shared decision-making. Early on, the magazine also deployed a “Wikipedian in Residence” to link Wikipedia entries mentioning certain tests and procedures to the appropriate Choosing Wisely guideline.
Still, though Choosing Wisely has given rise to more than 150 articles in peer-reviewed journals, it is too early to conclude that the conversations it sparks effectively curtail unneeded care. Even enthusiasts such as Erb acknowledge that in a system where doctors are still overwhelmingly paid more for doing more, asking people to pare their own paychecks is problematic.
“The Choosing Wisely campaign has done a great service,” says Shannon Brownlee, senior vice president of the Lown Institute and author of the book Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. “But culture will always trump checklists, however extensive, as long as most doctors and patients continue to believe at some level that more is nearly always better when it comes to medical care.”
The professional societies representing primary care physicians want doctors who reduce unnecessary care to be rewarded, rather than penalized. Additionally, they have been among the leaders pushing for changes in reimbursement, advocating the transition “from volume to value.” Cassel sees Choosing Wisely as part of that effort and hopes it expands from a campaign to a movement so powerful “that you couldn’t stop it if you wanted to.”
She adds: “Choosing Wisely was the right message at the right time from the right messenger.”