For EM, ‘Choosing Wisely’ is an Important, Physician-Driven First Step.
April of this year, the American Board of Internal Medicine Foundation
took a baby step in the cause of lowering the high cost of medical care
by initiating the Choosing Wisely campaign. The campaign asked physician
specialty boards, including ACEP, to identify “five tests or procedures
commonly used in their field, whose necessity should be questioned and
discussed.” They suggested, as many others have, that there are tests
and treatments that may be unnecessary at times and should be discussed
with patients before proceeding. The initiative represents low-hanging
fruit. So low, in fact, that 26 different specialty boards have now
signed on to the campaign and either have developed or are developing
their lists of tests or procedures whose necessity should be questioned.
It was a modest step at best.
A working group from ACEP addressed the idea of participating in
the project and ultimately decided to decline. With all due respect to
the College, I believe this to be a big mistake.
It is almost axiomatic at this point that Americans are often
overtested and overtreated. While I might disagree with some of the
specific findings of researchers like the Dartmouth Atlas Group (who
found wide disparities in Medicare treatment according to geography) the
basic premise is hard to refute. When EPM polled our readers to see if
there were routine tests and treatments that they might not need to do,
the results were overwhelming. Medical progress encourages constant
re-evaluation of the assumptions underlying our practice with constant
fine tuning, and our readers recognized this, which suggests to me that
this is a perfect time to move forward with Choosing Wisely. Progress
ensures benefit to the patient, our practice, and the health care system
as a whole.
The Choosing Wisely campaign seeks to foster discussion with the
patient of the current evidence, or lack thereof, for certain practices.
It does not suggest that we practice in a vacuum, but with consensus.
Let’s look at some of the “suggestions” of the Choosing Wisely campaign.
The American College of Physicians suggested that patients might
not need CT or MRI after a simple syncope. Their observation was that
without evidence of seizure or other neurological deficits, the evidence
did not suggest that patient outcomes were improved by these tests. Of
course, there are exceptions to this. And the devil is in the details.
But it provides a point of discussion with the patient concerning the
relative risks and costs, about which they may have an opinion.
The American Academy of Allergy, Asthma, and Immunology suggested
that patients consider foregoing antibiotics and/or CT in acute
sinusitis lasting less than two weeks. Haven’t we, as EPs, made this
same suggestion a thousand times?
At the risk of mischaracterizing ACEP’s deliberations, of which I
was not privy, it seems that the group agreed with the goals of the
campaign but feared two things. First, that this kind of unilateral
action by the house of medicine would lead to insurers refusing to pay
for the exceptional cases, as determined by an experienced clinician at
the bedside. Second, that such actions to reduce testing and treatment
could expose clinicians to an increased level of liability. There is a
nugget of truth in both of these reasons, but not enough, in my opinion,
to merit staying on the sidelines in this important step forward.
The issue of reimbursement may be real. But if a particular
medical test or treatment is not evidence based, and emergency
physicians can agree that it is often unnecessary, shouldn’t we question
whether there should be blanket compensation for it? If there are good
reasons for testing or treating an outlier, they should be stated and
explained. Will insurance companies use this as a club to beat
clinicians into submission? Possibly. But it is equally true that
clinicians can fall into reflex practice patterns that don’t reflect
good medical practice, and that causes costs to spiral unnecessarily.
The Choosing Wisely campaign is about questioning our reflexes, and
taking a moment to think about which tests and treatments we truly care
about as physicians. The campaign is more about communication than it is
about forcing changes in clinical practice. Doctors, talk to your
patients. Patients, talk to your doctor.
The liability issue may be real as well. We all fear missing
something and our response, if we’ve been burned, is to overtest and
overtreat. That way, at least I have a leg to stand on in court when the
inevitable bad outcome occurs. But this is a fear that we all live with
every day. We operate in a risky environment. Seeking zero risk is
simply not possible. So we seek to mitigate the risk. We take
reasonable, defensible risks. Will the cost/benefit argument help us in a
law suit? Probably not. Will avoiding an unnecessary CT save the
patient damaging radiation and the cumulative cost of millions to the
ACEP rightly noted that there needs to be progress on liability
reform. And liability award caps are only the beginning. Health courts –
or something similar – will be the only way to truly tame the beastly
cost of defensive medicine. But Choosing Wisely doesn’t mention
liability reform for two reasons. First, it is off target for medical
groups to point to others outside their sphere of influence while
ignoring those things that are under their control. Second, this is an
issue of leadership and ethics. Howard Brody, a physician and ethicist,
first suggested the idea of the Choosing Wisely campaign as a way for
physicians to stand up and lead our nation toward better health care.
Only physicians are uniquely capable of choosing what is best for our
patients. If costs must come down—and they must—shouldn’t we be the ones
leading the way? A stalemate is simply both sides refusing to move
until the other makes the first step. The eyes of the nation are upon
us. We should seize the moment to lead, and help to ensure that others
will not choose poorly—and then force those choices upon us
My greatest fear is that ACEP will lose this opportunity by
deferring action to another – and then another – day. Let’s study this
until we get it right. It’s sort of like writer’s block – something I
understand. Sometimes I’m paralyzed and can’t write the first sentence
for fear that I won’t complete the perfect piece. But sometimes we have
to seize the moment and take the first step. Choosing Wisely isn’t
perfect. But it is a gallant first step. We should join the effort and
lend our support.
Recently, M L Plaster Publishing Company LLC, the publisher of
Emergency Physicians Monthly, set about establishing the TentHouse
Foundation, a non-profit organization designed with the express purpose
of promoting sensible and sustainable health care solutions – ideas
which will shore up the foundations of this fragile house of medicine.
Many other organizations and individuals are doing similar work, but
TentHouse will be unique in that it is a grassroots effort by emergency
physicians. We have a unique perspective on cost-efficient,
compassionate health care and we can make a significant contribution to
this national discussion. The TentHouse Foundation will be promoting the
baby steps of the Choosing Wisely campaign. I hope that ACEP will
reconsider its position and take a leadership role instead of sitting on
Mark Plaster, MD is Founder and Executive Editor of Emergency Physicians Monthly