Putting Choosing Wisely into Practice


Am Fam Physician. 2018 Apr 1;97(7):432-433.

See related content: Choosing Wisely and Search Recommendations from the Choosing Wisely Campaign.

American Family Physician has highlighted the Choosing Wisely campaign in several editorials and articles over the past few years,14 and for good reason: decreasing unnecessary interventions protects patients from potential harms and reduces wasteful spending. Surveys show that primary care physicians are more likely to be aware of Choosing Wisely compared with other subspecialists.5 However, changing our practices to follow these recommendations has been less successful.

Several studies suggest that physician behavior has not changed in response to the Choosing Wisely recommendations. After publication of the American Academy of Family Physicians' Choosing Wisely recommendation to not use dual-energy x-ray absorptiometry (DEXA) to screen for osteoporosis in women younger than 65 years or men younger than 70 years with no risk factors, the number of inappropriate DEXA scans ordered for women younger than 65 years in a large ambulatory care network in the Washington, DC, area did not change.6,7 Another study created a composite score of adherence to 11 Choosing Wisely recommendations; researchers found that preoperative cardiac testing for low-risk, noncardiac procedures was the most prevalent low-value service performed (46.5%), followed by prescribing antipsychotics to patients with dementia (31.0%), prescribing opioids for migraines (23.6%), and ordering early imaging for acute low back pain (22.5%).8 A similar review using seven Choosing Wisely recommendations found mixed results: although unnecessary imaging decreased in accordance with two recommendations, unnecessary imaging related to five other recommendations did not change or increased.9

Changing long-standing habits can be challenging. A national survey of 2,000 primary care physicians' attitudes about Choosing Wisely found that the most commonly reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and tests recommended by subspecialists.10 Increasing awareness of the Choosing Wisely recommendations is an important first step, but physicians cannot be expected to shoulder the burden of implementing them. For meaningful change to occur, the workflows and systems we operate within must change so that new habits become routine.

What kind of workflow changes might enable family physicians to successfully implement the Choosing Wisely recommendations? For starters, electronic health records should help—not hinder—us. Electronic health record technology should take into account each patient's medical history so that order alerts are triggered for patients meeting specific criteria. For example, alerts should be triggered when ordering DEXA for a low-risk woman younger than 65 years or when ordering an antipsychotic for a patient with dementia.

Responding to patient requests for unnecessary interventions may be more challenging, but those conversations do not have to be handled only by physicians. Nurses, medical assistants, and physician extenders can reinforce the message, for example, that antibiotics do not help most colds, sinus infections, or otitis media episodes. Having an office algorithm for triage nurses to follow when patients call to request antibiotics for these conditions can empower them to counsel patients on other interventions instead. An office team might also review the Choosing Wisely recommendations and choose one or two on which to base a quality-improvement project.

Health systems can facilitate conversations with other subspecialists about these interventions, too. Instituting policies that outline which procedures do and do not require preoperative cardiac testing, for example, can ensure that a patient who is having a cataract removed will not be reflexively scheduled for an exercise stress test.

Plans that rely on an individual to remember to make a change typically are not successful.11 However, individual physicians can take a leadership role in helping build workflows and systems that facilitate change. The challenges to implementing Choosing Wisely are likely different across our practices; as such, the solutions should be created locally to maximize buy-in and the chance of success.12

It is our responsibility as physicians to help our patients avoid interventions that are not helpful or, worse, potentially harmful. Our finite pool of health care dollars should not be wasted on interventions that do not help patients to live better, healthier lives; every dollar wasted on unnecessary care cannot be spent on necessary care for underserved patients. The Choosing Wisely campaign challenges us to find ways to make these changes to benefit our patients. It is up to each of us to figure out how to put it into practice.

The author thanks Dr. Joseph Gladwell and Dr. Kenny Lin for assistance in the preparation of the manuscript.

Address correspondence to Jennifer L. Middleton, MD, MPH, at jennifer.mton@gmail.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.


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2. Siwek J, Lin KW. More ways to improve health and reduce harm: Choosing Wisely phase 3. Am Fam Physician. 2014;89(5):329.

3. Siwek J, Lin KW. Choosing Wisely: more good clinical recommendations to improve health care quality and reduce harm. Am Fam Physician. 2013;88(3):164–168.

4. Siwek J. Choosing Wisely: top interventions to improve health and reduce harm, while lowering costs. Am Fam Physician. 2012;86(2):128–133.

5. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337–343.

6. Lasser EC, Pfoh ER, Chang HY, et al. Has Choosing Wisely affected rates of dual energy x-ray absorptiometry use? Osteoporos Int. 2016;27(7):2311–2316.

7. Choosing Wisely; AAFP. Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. April 4, 2012. http://www.choosingwisely.org/clinician-lists/american-academy-family-physicians-dexa-screening-for-osteoporosis. Accessed July 30, 2017.

8. Colla CH, Morden NE, Sequist TD, Schpero WL, Rosenthal MB. Choosing Wisely: prevalence and correlates of low-value health care services in the United States [published correction appears in J Gen Intern Med. 2016;31(4):450]. J Gen Intern Med. 2015;30(2):221–228.

9. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign [published correction appears in JAMA Intern Med. 2015;175(12):2003]. JAMA Intern Med. 2015;175(12):1913–1920.

10. Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bernstein SJ, Kerr EA. Perceived barriers to implementing individual Choosing Wisely recommendations in two national surveys of primary care providers. J Gen Intern Med. 2017;32(2):210–217.

11. Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf. 2017;26(5):381–387.

12. Toussaint JS, Elmer M. Why best practices fail to spread. Fam Pract Manag. 2017;24(1):17–20.



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