For EM, ‘Choosing Wisely’ is an Important, Physician-Driven First Step.

In 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 nation. Certainly.

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 the sidelines.

Mark Plaster,  MD is Founder and Executive Editor of Emergency Physicians Monthly