WhiteCoat

Choosing Wisely – Good Medical Practice or Prelude to Rationing?

EP Monthly has an important Pro-Con debate between ACEP President David Seaberg and EP Monthly founder Mark Plaster about the “Choosing Wisely” program.

Choosing Wisely is being pushed by the ABIM Foundation as a way to get specialty societies to label certain tests as “unnecessary” or of questionable benefit.

I side with Dr. Seaberg in this argument.

I disagree with the concept some people advance that we need to essentially “do it to ourselves before someone else does it to us” (see the comment to Dr. Seaberg’s position). Reasoning like this is how physicians and patients have lost much of the control of the house of medicine. Read through the news and look at the emphasis on reducing the amount of “unnecessary” care. Just last week, the Washington Times published an article about how the Institute of Medicine stated that we waste $750 billion each year in health care. How could anyone disagree with reducing that which is “unnecessary”? It’s a great sound bite. But as Dr. Plaster notes in his article, the devil is in the details.

How do we define “unnecessary”? A pregnancy test in a male patient is “unnecessary.” No way to justify its use. But other tests which seem to have little clinical utility may be deemed “necessary” for non-clinical reasons. A CT scan may only infrequently show the etiology of a patient’s syncope, but some doctors may believe the CT scans are “necessary” to avoid accusations of improperly evaluating a patient or to prevent being sued for missing a rare neurologic cause of a patient’s syncope. If we want to decrease the amount of “unnecessary” testing, we need to address all of the reasons that such testing is performed. Why doesn’t Choosing Wisely change the preamble of its campaign to include: “The following tests are medically unnecessary and no type of professional or legal liability should ever be imposed upon physicians for failing to order or perform them …”?

I question whether the ties that several ABIM foundation trustees have to the Obama administration (hat tip to A Line of Sight) will affect the mission of this project.

Finally, many of the groups listing “unnecessary” testing in the Choosing Wisely campaign are making their directives at other specialties. Radiologists are telling emergency physicians not to order so many CT scans. Neurologists are telling emergency physicians not to order CT scans for migraine headaches. Unless those specialists are going to come to the emergency department, evaluate the patients, and follow their own recommendations, they have no business telling other specialties what to do. Easy to point fingers when you have no skin in the game.

We need to reduce the amount of testing performed in this country, but I still think that the best way to do so is through deregulation and free market principles. If patients want to pay for a test with little clinical validity, they should be able to do so. They should be able to have the test done ten times if they want to pay for it.
Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing.

In this respect, I predict that Choosing Wisely just won’t work for its intended purpose and it will likely be used as a first step toward rationing care – especially care that ends up with “normal” results.

11 Responses to “Choosing Wisely – Good Medical Practice or Prelude to Rationing?”

  1. Nurse K says:

    I think expensive tests for symptoms that are not usually associated with the condition that they’re being checked for should not be ordered. Call that rationing or just being a good doctor. Whatever.

    Seriously, name me one time when someone who “fainted” who was at their neuro baseline upon awakening had some sort of head bleed? Yet, doctors in my ER order head CTs and/or MRIs routinely for this stuff.

    Also, I think, when you just have a routine of hearing something like “fainting in an old person” and your default is to just scan ‘em and order a few labs and an EKG, you might miss the actual cause of the problem, such as someone taking too many sedating medications, or something as simple as forgetting to eat dinner or drink water on a hot day.

    What’s the problem with taking suggestions on what tests could be avoided to save time/money, especially when most ERs in the country are experiencing record volumes? Having official groups for various specialties declare the tests generally unnecessary is a good legal cover as well.

    • DensityDuck says:

      “What’s the problem with taking suggestions on what tests could be avoided to save time/money”

      The problem is that when you don’t do a test and you miss a condition and a patient dies, “I was following the Choosing Wisely guidelines published by the ABIM Foundation” isn’t going to save you from the inevitable malpratice lawsuit.

  2. Mary says:

    I am sure it is much more complicated than this, but the bottom line is, we, as a nation, cannot afford to do everything medical, for everybody. Some difficult choices must be made, or the national debt will continue to spiral out of control. The question is, who gets screwed? I am guessing it will be the poor and undereducated, who often don’t vote, and cannot afford a lobbyist.

  3. From the ER standpoint, “unnecessary” is easy to define – that with little or no usefulness in the emergency setting – ie something not done to rule out something urgent or emergent. Er docs are terrible with ordering so much shit – because is it too easy for us to do it! (and patient’s and PMD’s demand it)

    • WhiteCoat says:

      So you think workup of patients post gastric bypass and abdominal pain is “necessary” testing in Nurse K’s contest.
      Another physician didn’t think so and discharged the patient home without any testing.
      Who’s right?
      And if you’re the patient on whom something is missed, how do you feel if a doctor missed the diagnosis because the testing to find the disease was labeled “unnecessary”?

      Also, a head CT in a patient with a migraine headache may be intended to rule out an emergent brain bleed – even if that bleed has little chance of being present.
      Necessary or unnecessary? After all, it was performed to rule out something urgent or emergent …
      See my point?

      But you’re right that many other outside influences affect whether tests are ordered.
      Can you say “Press Ganey”?

      • Nurse K says:

        1. The patient in question said she would refuse any lab tests that were ordered because she didn’t like needles.

        2. After talking to her, it turns out she had no BM x 5 days. Her pain was mid-abdomen down into the lower abdomen, worse with movement, not worse with palpation, and she personally felt as if it was constipation, but wasn’t sure.

        3. Her blood pressure and pulse were normal.

        4. After ODT Zofran, she was able to tolerate water and some bites of applesauce. She never vomited in the ER.

        5. Now what do you think? Huge workup with CT?

      • Nurse K says:

        Indcidentally, she was very happy with the ODT Zofran and lack of lab draws.

  4. jennyct says:

    Note that of the cost of $750 billion wasted, only 17% is from overuse of testing. The rest is as follows: excess administrative costs ($190 billion); inflated prices ($105 billion); prevention failures ($55 billion), and fraud ($75 billion). Why are we not hearing about the other factors?

    The physician needs to educate the patient on which tests are necessary, and what the risks are. Restrict too much and some will lose their lives. With 30% of diagnoses being incorrect (Sloan et al, 1993), can you blame some individuals?

    If the patient wants to pay for it, it should be an option. Think about it. A month goes by with no resolution. You tell him to give it two more months. Now the patient starts getting depressed and needs to go to a psychiatrist. Where’s the savings there?

    Anecdotally, I needed two HIDA scans for a diagnosis of acalculus gallbladder disease. After resisting the second test for years, I finally gave in. But you don’t want to know what I went through in the meantime.

    COMMON SENSE should prevail.

  5. chadpdx says:

    a bit late for comment I know but I think a response should be made to the statement by the author to let free market principles dictate use. Free market conditions do not exist in medicine. There are no knowledgable transactions being made unless the patient is also a physician. Ultimately the decision IS up to the patient but with the guidance of an expert in medical matters. That guidance should be given with only the patient’s benefit in mind not the physician’s.

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