Sometimes the most effective treatment a physician can offer is sage advice rather than a prescription medication or testing, a principle that is foundational to the Choosing Wisely campaign.(www.choosingwisely.org)
Arthur Hong, M.D., an assistant professor at the University of Texas Southwestern Medical Center in Dallas, discusses his research and clinical approach to reducing unnecessary medical services during an event to commemorate the fifth anniversary of the Choosing Wisely campaign.
To commemorate the campaign's fifth anniversary, physicians and health policy experts participated in a series of panel discussions on Oct. 24 to share stories about how this approach has helped reduce the use of costly and unnecessary medical services.
The American Board of Internal Medicine (ABIM) Foundation and Consumer Reports formally launched Choosing Wisely in 2012. Nine medical specialty organizations -- including the AAFP -- joined the initiative at that time; since then, more than 80 medical specialty groups have signed on to encourage clinicians to steer patients away from treatments that do not demonstrate measurable health gains.
"Choosing Wisely is about clinicians engaging in conversations about the potential of overuse and harm from unnecessary procedures," Richard Baron, M.D., president and CEO of the ABIM and ABIM Foundation, said at the event.
Those conversations are often exactly what patients want. Arthur Hong, M.D., an assistant professor at the University of Texas Southwestern Medical Center in Dallas, recalled an encounter with a patient who had lower back pain. The patient, who was a radiologist, asked hesitantly about scheduling an MRI even though he knew from his professional experience that it was not the best approach.
"He really wanted some reassurance," Hong said. "That's what we provide in medicine. More care is not always better. The right care is best."
When Choosing Wisely began, little research existed on overuse of certain medical services, procedures and interventions despite recognition that as much as 30 percent of health care spending was wasteful.
The initiative specifically targeted several protocols for reductions, including imaging for lower back pain, antibiotics for upper respiratory infections and preoperative tests for cataract surgery. The list continues to grow through recommendations from specialty societies, and many health systems have added tools to their electronic health record systems to help identify procedures that might be unnecessary.
Encouraging clinicians to focus on unnecessary services was difficult at first, given the existing demands of patient care and record keeping.
"Clinicians are overwhelmed, and Choosing Wisely felt like one more thing to do," Eric Wei, M.D., interim chief quality officer at Los Angeles County + University of Southern California Medical Center, said of the initial reaction among medical professionals. "They've heard many people say, 'It's just a few more clicks.'"
But the benefit to patient care was often clear. For example, reducing the backlog of patients waiting for an MRI allowed cancer patients with serious conditions to get in sooner, Wei noted.
A report(www.choosingwisely.org) issued to commemorate the initiative's anniversary highlighted specific achievements. For example, Kaiser Permanente of Washington reduced antibiotic use by 35 percent by meeting with clinicians in areas where their use for upper respiratory infections was high. Froedtert and Medical College of Wisconsin reduced antibiotic use by 42 percent and imaging for lower back pain by 60 percent. Cornerstone Health Care, a rural physician group in High Point, N.C., reported significant reductions in antibiotic use, dual-emission X-ray absorptiometry scans and annual Pap tests.
"Overuse of medical services isn't a new problem," said Eve Kerr, M.D., M.P.H., a professor of internal medicine at the University of Michigan Medical School in Ann Arbor. "Choosing Wisely accelerated our understanding that we need to do something about it."
Matt Handley, M.D., senior medical director for quality and safety at Kaiser Permanente of Washington, pointed out that patients who ask about treatments they learn about from ads or online searches are really looking for sound medical advice.
"It's not a demand for care," said Handley. "It's an uninformed request. They're just asking. We have to demonstrate empathy and understand what the patient wants."
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