“Choosing Wisely”–A great name for a great plan.

Cycling Wednesday has to be postponed this week. There is indeed a more pressing and relevant health matter that has come to light today. I am talking huge news; a story ripe with optimism and hope.

Let me tell you about a possible paradigm-changing idea in the seemingly hopeless matter of controlling runaway healthcare costs—a topic that has far-reaching implications, not just for healthcare, but for our nation’s economy and vitality.

The news:

Organizations of doctors have decided to embrace common sense in the practice of Medicine. Led by the American Board of Internal Medicine Foundation and joined by many other medical societies, the Choosing Wisely movement aims to promote care that is…listen to this…

  • Supported by evidence,
  • Not duplicative,
  • Free from harm,
  • Truly necessary.

Nine medical groups—with more coming on board soon—were asked to compile a list of 5 misused or overused tests. The American College of Cardiology listed these ground-breakers:

  • Cardiac imaging should not be performed routinely in patients without symptoms or high-risk.
  • Cardiac imaging should not be performed for routine follow-up in patients without changes in symptoms or signs.
  • Cardiac imaging should not be performed prior to low-risk surgery.
  • Echocardiograms should not be done to follow-up non-symptomatic patients with mild valve abnormalities.
  • Patients with heart attack treated with emergency stenting should have stents placed only in the culprit vessel.

These are not misprints. The leaders of American cardiology have gone on the record against nonsensical and wasteful–but some say ‘thorough’ testing. Wow!

As a minimalist and (budding) master-of-the-obvious clinician, these proclamations of common sense make my heart sing. But that’s not all. Choosing Wisely isn’t just about smarter Cardiology recommendations. (Although, if implemented, these heart recommendations alone would greatly reduce unnecessary healthcare costs.) Other medical societies have weighed in with equally ‘epic’ suggestions:

  • Radiologists recommend performing fewer head imaging studies for headaches and fewer chest CTs in the initial evaluation of suspected lung blood clots (PE).
  • Family doctors urge doing fewer MRIs for low back pain and prescribing antibiotics less aggressively for uncomplicated sinusitis.
  • GI doctors call for less repeat colonoscopies after an initial negative test, fewer CT scans of the abdomen and titration to the lowest dose of medicine to treat reflux.
  • Internists repeat the call for fewer MRI scans of the low back, avoiding head-imaging tests for simple faints, and echo the ACC recommendations to not do routine stress tests in low-risk patients.

This stuff is huge. We all know healthcare costs are spiraling out of control. Most agree that the reforms argued in front of the Supreme Court last week don’t address the issue of controlling costs. Government regulation tries to limit costs by covertly (or overtly) inserting itself in the doctor-patient relationship.

Effective healthcare reform will not come from the government.

Doctors must design and implement healthcare changes and reforms. Call us what you will, but we are the experts in medical diagnosis and treatments. We know what works and what doesn’t. We must be allowed to practice Medicine–not just follow protocols, or test and treat just to cover our butts. The corollary here, of course, is that we must be allowed to be human. What my favorite cyclist, Fabian Cancellara, says about cyclists holds true for doctors too: “We are not cyborgs, only men.”

That our thought leaders are now proclaiming–and social media is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.

Gosh…Writing about this feels so good. Not just because my approach to the practice of Medicine has come back in vogue, but because I care so much about the human aspects of our profession. Because it matters so.

If only I had thought to name my blog, Choosing Wisely.

JMM

Comments

  1. Jay says

    John,

    My first impression on this website was similar and I tweeted favorably about this yesterday. I’m glad to see you feel the same way. I’d urge people to look up the individual lists yourself as the way they are presented is part of the appeal. It looks like some talented marketing folks were involved in this campaign.

    After my tweet, cardiology fellow @MGKatz036 and I got into a friendly exchange (it’s up on my twitter stream @EJSMD if you want to take a look). He’s concerned about these kind of checklists further mandating care and devaluing individual decision making.

    Maybe I’m naive, but I still think this is the right way to go about making needed reforms. These are solid peer reviewed guidelines that aren’t well appreciated (except when it’s time to answer questions on board exams). Many of us have fallen into the trap of routinely ordering unnecessary tests to meet local standards and shield from malpractice exposure. These steps may give well meaning caregivers the “cover” they need to treat patients appropriately.

    Let’s just hope the central powers that watch over us don’t co-opt “Choosing Wisely” and turn it into “We Have Chosen for you and it would be Wise for you to agree.”

    Jay
    @EJSMD

  2. Mark F says

    The approaches you mention have a great potential to lower medical costs. However, as long as the ever-present threat of a malpractice suit (by omission of treatment) lingers at every patient interaction, any doctor who wishes to continue practicing will not actually follow these suggestions. And I don’t expect this issue to be fixed anytime soon. Great ideas, won’t ever happen.

    • says

      Maybe not tomorrow, but in the future perhaps. The first step is for thought leaders to validate nuance. This is why this program gives me hope.

    • Melvin says

      Mark F,
      If you are a physician, I would not seek your care. Mindless, defensive medicine is gross. It is too bad that professional associations and licensing
      authorities won’t crack down on mindless, defensive medicine. It only breeds
      distrust of doctors and hate for the waste they generate. It makes one want to root for the insurance companies.

  3. Don says

    As long as the threat of malpractice litigation hangs over every “bad” medical outcome I don’t see how it will be possible to contain costs. I am neither a lawyer nor a doctor, but even I can see that reform of the laws regarding malpractice is a necessary part of health care reform.

  4. frank says

    would you be so excited about the care cut backs, if a loved one were concerned ? as far as malpractice hanging over you, got to have something to keep pros ” on the ball ” not knocking ideas, just think how much is for show and how much is from the sincerely well meaning.

  5. says

    The threat of malpractice is not nearly as big a problem as the threat of “volume”. As long as primary care doctors are paid unequally for the time we spend with patients, it will continue to be easier to order a test or prescribe an antibiotic than to spend the necessary time to explain why these are unnecessary and even dangerous. Our reimbursement structures must be changed for these problems and a host of other ones that are impacting good patient care in our system to go away.

    • says

      I could not agree more. Take pacemakers and ICDs: it takes far more energy–both mental and emotional–to explain why we should NOT do the procedure than it does to simply do it. And the compensation for not doing, or practicing smart medicine, is way less. What’s more, the doctor’s risk of not doing something may be higher.

      But this is why I like Choosing Wisely. It’s a start. Thought leaders saying this stuff is big. Social media may amplify the message. Then smart medicine becomes ‘normal.’ I know…dreamy.

  6. says

    John – I fully agree that “choosing wisely” is an important 1st step that should be applauded. That said – I personally doubt that we’ll ever solve the problem of skyrocketing medical costs until there is movement to a single-party payer … since even if “choosing wisely” DOES succeed in significantly reducing certain unnecessary procedures (not guaranteed, given lingering concerns as per some comments above about malpractice) – the costs of medications, procedures that are still “deemed necessary”, hospitalization, reimbursement, etc continue to skyrocket out of control – as do costs for health insurance and malpractice. I simply think the paradigm for payment/reimbursement needs to change …

    • says

      Agreed. Some say cutting salaries of docs will de-incent students to choose Medicine. That’s true to an extent, but if you ask most doctors what they are least happy about, I bet they’d say it’s the non-clinical work and regulatory intrusions into the doctor-patient relationship.

      Again, that’s why I like Choosing Wisely. To me, anything that is smart and nuanced, for doctors and by doctors will equal better outcomes for patients.

  7. says

    The “Wise Choices” program is just not resonating with me. While no one will argue for unnecessary testing, I just can’t see how restricting access to antibiotics will lower the nation’s health care bill. Speaking as a consumer, with a chronic ear which is now perforated from a runaway untreated sinus infection, it chills my soul to think of this bullet point becoming a mandate of NO DRUGS FOR SINUSITIS. I only have one more eardrum left. There was an article in the NYT awhile ago discussing the cost of health care, and their question was “why does stuff cost so much?” Why is an MRI here so much more expensive than elsewhere. Why is a bag of saline between $90 and $171 depending on where you are? Why does saline cost that much? A woman I know recently broke her collar bone mountain biking. Her Canadian issued travel insurance maxed at $15k. The first estimate to fix it was $40k. Her husband starting calling around and negotiated the price down to $7200. If that had been me, with my employer provided insurance, I would have taken the $40k because a) I have no incentive to shop the cost, and b) I have no way to shop the cost. My insurer decides how much my health care costs. Controlling the cost of medical care is going to take more than doctors cutting back on head scans. Medicine really can not be compared to dry cleaners, but once dry cleaners were compelled to post their rates, costs went down. One of the many problems with that simple minded analogy is that no one has dry cleaning insurance. Maybe if medical costs went down, health insurance could morph from a pre-paid health care plan to actual insurance.

    • says

      All good points Allison. In Germany, AF ablation costs 8000$ and here it costs 80,000$. Same procedure with the same outcomes. What’s more stinging is that all Germans have basic health insurance. The rich are free to buy ‘Cadillac’ plans but the doctors I spoke with all had the basic plan.

      And that’s all I’ll say about that.

  8. Mark Paulsen says

    Allison,
    Maybe you don’t need to have your collarbonen “fixed” at all. The vast majority of collarbone fractures will heal with some time in a sling and maybe some physical therapy. Couple visits to your PCP and one x-ray. A few hundred dollars.

    I agree that Choosing Wisely feels good, but it is discoraging to think we have gotten down to this. Looking back over my 20 years as a primary care doctor, I see that one of my most important and most rewarding functions has been to protect my patients from The System. I am proud of helping people choose wisely. I have been sued but not for this sort of thing, and now gettiing sued for choosing wisely is the least of my worries.

    • says

      Thanks Mark…

      My partner and I sit in adjoining cubicles in the office. We both make our living doing, as interventionalists. Fixers we are.

      It’s funny; we used to talk about the rigors of how hard a day we had in the lab. Now, we both complain most about the difficulties of doing less, or daringly, nothing at all.

  9. says

    Excellent points Allison. This is why I’ve felt the ONLY way health care costs overall will go down is IF there is a single-party payer. The reason why a bag of saline costs so much is because no limit has been set. Obvious result is that the cost of a bag of saline will probably be substantially more next year and even more the next. Those with employer paid insurance can get care (albeit with whatever deductible they pay) – but these days no one except the very rich can pay out of pocket for medical bills (ie, those without health insurance are no more than one serious illness away from potential bankruptcy).

    And as to your last point – maybe medicine should learn something from the dry cleaners. One of my family members just had a “preventive colonoscopy”. No one (that is, no one) could come close to telling her how much her total cost would be. It cost well over $1,000 out of her pocket after her good insurance paid – and bills kept coming for months. When one buys any other item in a store – you are given a price, and that is what you pay. Should be the same with medicine. I can’t see that happening unless there is a single-party payer that limits the amount that can be charged …

    “Choosing Wisely” IS an important 1st step. But lots more in the area of limiting what is charged will need to be done.

  10. says

    I wanted to THANK Dr. John for regularly taking time out of his busy day to soul-searchingly, openly, and non-defensively write this blog, with bonus of specific answers to feedback from participants in his column. Doing so not only provides information on his cardiology specialty- but also insight on the practice of medicine (as well as life experiences and pleasures like biking). Thank you Dr. John!

  11. Verted says

    Why is it insurance will pay for a $3,000 CT scan, a $250 per month anti-arrhythmic drug (of dubious usefulness) prescription, but not a $35 blood test for possible magnesium deficiency for afibers?

    And why is it the bill for a 2 hr visit to the ER for $8200 can be negotiated down to $1800 by the insurance company? You would think that by that logic that $1800 SHOULD be the real price, as obviously money is being made at that level.

    Medicine should be Patient Centered, not Payment Centered.

  12. verted says

    OK, I’ll temper that last comment, as medicine is a business as well. I should have said “medicine should be more patient centered and a bit less payment centered”. My apologies to all of the good medical folks out there who make their living doing some unbelievable work

    It is a tough business to know where to cut costs and figure out the bottom line, as there are so many players involved with the providers, the regulations, the insurance companies, and mounds of paperwork.

    One of the very best GPs I ever had told me he just wanted to retire, set up a small practice in his home for his long time patients, and make it a “cash only, pay me what you, when you can practice”. He was getting tired of all the red tape and headaches.