Of Wise Choices, Evidence That Matters, and Leaving Old Friends Behind
Am Fam Physician. 2016 Oct 1;94(7):540.
Tradition is no longer the bedrock of practice. Better medical research and better delivery of its results make change easier and more necessary. And we have help.
In this issue, Drs. Grad and Ebell point out the consistency between two efforts to foster change in practice.1 The first, the Choosing Wisely campaign, identifies wasteful and unnecessary medical tests, treatments, and procedures—not to prohibit them but to get physicians and other health care professionals thinking more critically about clinical recommendations they previously took for granted. The second, Daily POEMs (patient-oriented evidence that matters), are concise summaries of recent research studies that evaluate an outcome patients care about and present conclusions that may spark readers to change their practice.2
Based on feedback from approximately 1,300 physicians for each POEM summary, the authors identified several time-honored practices that should be shelved, ranging from recommending common treatments such as arthroscopic surgery and platelet-rich plasma for knee pain to screening asymptomatic individuals with computed tomography angiography for coronary artery disease. It's not that the interventions are expensive; they either don't work or present excessive risk compared with the provided benefit.
Abandoning these practices won't be easy, especially for clinicians who have done them for a while. Leo Tolstoy observed, “I know that most men . . . can very seldom discern even the simplest and most obvious truth if it be such as to oblige them to admit the falsity of conclusions they have formed, perhaps with much difficulty—conclusions of which they are proud, which they have taught to others, and on which they have built their lives.”3
But, contemporary medical practice is a continuous process of updating and change. This is not the entertaining “coffee is good for you/coffee is bad for you” pseudoscientific clickbait that populates websites. It is carefully analyzing new research findings for validity and relevance, weighing risks and benefits, and then placing the new findings into context with our existing knowledge. Although it is impossible for clinicians in primary care to stay abreast of all new findings on our own, there are updating services to create summations for us.
Change is inevitable; the choice is whether to change or be changed. Most of us don't like to be told to change. Initiatives such as Choosing Wisely and updating services such as Daily POEMs let us decide what's best to do based on unbiased, updated information. The crowdsourcing method for identifying clinically relevant topics most worthy of critical scrutiny gives us further comfort.
Every aspect of patient care—every word we say, every test or exam we perform, every treatment or procedure we employ—carries with it the possibility of harm as well as the opportunity for benefit. Although eliminating overuse is often perceived as a way of cutting medical costs, it is really about decreasing wasteful, unnecessary testing and treatment that offer only the potential of harm without the corresponding possibility of benefit. Sometimes, we need to leave our old friends behind.
editor's note: Dr. Shaughnessy is one of the editors of Daily POEMs and a contributing editor to AFP. Because of Dr. Shaughnessy's dual roles, this editorial underwent peer review and editing by three of AFP's medical editors. Dr. Shaughnessy was not involved in the editorial decision-making process.
1. Grad R, Ebell MH. Top POEMs of 2015 consistent with the principles of the Choosing Wisely campaign. Am Fam Physician. 2016;94(7):566–570.
2. Essential Evidence Plus. http://www.essentialevidenceplus.com/. Accessed July 13, 2016.
3. Tolstoy LN. What Is Art? Maude A, trans. New York, NY: Thomas Y. Crowell & Co.; 1899:124. https://archive.org/details/WhatIsArt_527. Accessed July 14, 2016.
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