Choosing Wisely

New post up at Medscape/Cardiology — Heart Rhythm Society’s Choosing Wisely List is tentative and cursory

February 14, 2014 By Dr John

The Choosing Wisely campaign began in 2009 when the American Board of Internal Medicine (ABIM) Foundation invited medical societies to own their role as “stewards of finite healthcare resources.” The movement aims to promote care that is supported by evidence, not duplicative, free from harm and truly necessary. That sounds delightful, and I wrote enthusiastically about Choosing Wisely back in 2012.

It appeals to me because it addresses core problems in US Healthcare–inefficiency, excessive action and paternalism. While Choosing wisely informs patients, it targets doctors to do their part in stopping the madness–of overtesting, overdiagnosing and overtreating. Choosing Wisely is special because it comes from doctors not policy wonks or third-party payers.

It felt strange to me that the Heart Rhythm Society waited so long to release their list of 5 Don’ts. Why was this? The optimist in me had hoped that the delay meant HRS leadership was working hard at designing a meaningful and robust list. A recent New England Journal of Medicine Perspective piece made it clear that while some medical societies looked inward and made tough calls ( American College of Cardiology), others phoned it in ( American Academy of Orthopaedic Surgeons)^.

A Choosing Wisely list from HRS is important because of the nature of electrophysiology. Heart-rhythm therapies are no small thing. Our interventions are big, expensive, and almost always preference sensitive. These are therapies that may provide great benefit but also come with significant burden. It’s one thing to overuse pink-eye treatments, it’s another to overuse shocking devices, catheter ablation, or antiarrhythmic drugs.

Finally, this week, HRS released their list of “Five Things Physicians and Patients Should Question^.”

I didn’t like the list at all. Some recommendations left out important details, others stated the obvious, and two bordered on insulting. What a lost opportunity for leadership.

Now what? How can I be critical of the Heart Rhythm Society? These are smart and accomplished people. Dr Hugh Caulkins from John Hopkins is HRS president. One time, early in my AF ablation experience, I called him to ask a question about a patient problem. He didn’t know me but took the time to take my call. On the phone he was kind, patient and useful. Dr. Rich Fogel from Indianapolis is president-elect. I worked with Rich when I moonlighted during fellowship. He’s a great guy. He cares. Others on the list of HRS leadership, I haven’t met, but I respect their work.

It’s not easy to be critical of this group. That said, opinion commentary is my job description over Medscape Cardiology–the old theHeart.org.

My post is 2200 words. In part 1, I give a letter grade to each of the 5 HRS Choosing Wisely lists. The commentary gets into technical medical issues but the theme is that the list was cursory and tentative. In part 2 of the post, I suggest more worthy items for an electrophysiology list. These include, paying more attention to the ICD generator change, increasing the shared decision-making process in ICD decisions, cutting back on overtreatment of atrial fibrillation, especially in the elderly and a host of other “littler things.”

One more teaser: I’ll give you my conclusion:

One of the reasons I was drawn to cardiology as a young learner was that we were leaders. I saw cardiologists as bold and courageous. We led the medical community in clinical science. We did not back down from challenges.

In another era, the challenge of medicine was finding better treatments of acquired heart disease. It wasn’t long ago that patients with MI were treated with bed rest and opiates. We’ve come a long way. We’ve done a lot.

But these are different timesâ€”with different challenges.

The challenge for medical doctors and their societies now is not about delivering more medicine and surgery; it’s about using our many tools wisely and aligning them with our patient’s goals.

The game has changed. Can we?

I hope you want to read the entire post. The title of it is Heart Rhythm Society’s Choosing Wisely List Disappoints

JMM

Successful US healthcare reform must consider human nature

October 6, 2013 By Dr John

Reform of healthcare in the United States is infinitely complex. Millions of words have been written. The noise drowns out the signal. It’s rare therefore that one paragraph could sum up the problem so concisely.

It came from Edward Davies, an editor at the British Medical Journal. He was quoting journalist Owen Dwyer who was writing on the challenge of doing less.

â€œHow many of us would voluntarily take steps that slash our income, and that of our employees, while simultaneously alienating our customers? That is what US physicians are being asked to do. Only a physician of rare moral courage could push back alone against these relentless pressures, which is why physicians are now being asked to try collectively.â€

As many of you know, I am a vocal advocate for both the Choosing Wisely campaign from the American Board of Internal Medicine Foundation and the Less is More movement from Dr. Rita Redberg at JAMA-Internal Medicine. These ideas, which urge doctors to practice less disruptively, fly in the face of human nature. No headwind is tougher to pedal against than human nature.

Consider the roofer anecdote: How many times has a roofer looked at your roof (which you cannot see) and told you: “No sir, your roof is fine; you don’t need any of my highly profitable services.”

I often kid around with patients and proclaim that I am the only doctor in this city trying to make less money. Hyperbole? Yes, surely.

But the point is that when I practice less disruptively; when I teach patients to help themselves; when I give time a chance to cure, and when I do fewer procedures, there are certainties:

I practice the best medicine possible;
I come home mentally and emotionally fatigued;
I hurt my productivity;
I endanger my referral base;
I might just expose myself to liability risk.

These are the problems that ObamaCare does nothing to address. These are the hard problems.

Read that quoted paragraph again. Then put yourself in the shoes of a young doctor who does not have a stable referral base, adequate savings or paid off student loans. Consider what the good young doctor does have: a compliance officer breathing down her neck to prescribe guideline-mandated ‘quality’ care, twenty other patients to see before she picks up her kids at day care and maybe even the false idea that more care is better care. Does the good young doctor know that said guidelines are born from medical societies with financial ties to industry? Does she realize that today’s quality care might be tomorrow’s medical reversal?

It’s a mess.

The complexity of it all always leads me back to the same basic and obvious things.

To patients: I say take care of yourself. Make good choices and stack them together. Such is not a guarantee, but it improves your chances of avoiding this imperfect business.

To doctors: I say go slowly and think. Aim for less disruption. The human body can do a lot if we let it.

To medical educators: You have one shot with these young people. Teach them well. (Not everyone gets the benefit of Hoosier wisdom, but you can get close.)

And to policy makers: Please pay more attention to the contact points of healthcare–that is, where human doctors meet human patients. Human nature is a stiff headwind to go against. Ask real doctors to help you, even cardiologists.

JMM

See also this Storify Twitter thread published by my colleague Jay Schloss (@ejsmd).

New Post up on Trials and Fibrillations: My Choosing Wisely list for electrophysiology

April 10, 2012 By Dr John

In the Choosing Wisely initiative, nine medical groups have contributed their list of five misused and overused tests and treatments. Some of the highest cost-of-care groups are on board–cardiologists, oncologists, radiologists, nephrologists (kidney) and gastroenterologists. Front line doctors, like internists and family doctors, have also weighed in.

Coming soon are lists of five from the palliative care doctors, geriatricians, rheumatologists, allergists, ENTs, echocardiographers and this ever-important group, the hospitalists.

Notably missing from this influential groups of doctors is my specialty, the Heart Rhythm Society. That’s really unfortunate, as I believe we could (and should) contribute greatly to the important mission of Choosing Wisely. For two reasons:

–First is the expanding healthcare behemoth of Atrial fibrillation (AF), the chief disease that heart rhythm docs treat. AF is the number one cardiac reason that patients are admitted to a hospital and it affects approximately 3 million US patients (and is growing in prevalence). Patients with AF enjoy a rapidly expanding array of innovative yet expensive technologies, including new blood thinners, new catheter ablation techniques and surgical therapies.

–The second reason why Heart Rhythm doctors should contribute stems from our use of invasive and costly devices. On the one hand, pacemakers and defibrillators (ICDs) offer selected patients incredible benefits, but on the other hand, they can also burden patients with costly and dangerous adversity.

It’s for these reasons that I offer my list of five “Don’ts” in the field of heart rhythm medicine (electrophysiology.)

Trials & Fibrillations -- theHeart.org

The full post is up on the Trials and Fibrillation blog over at theHeart.org.

My AF peeps won’t be disappointed; the over-treatment and mis-treatment of AF makes the list. Here is an excerpt:

(5) Do not overtest or overtreat low-risk patients with atrial fibrillation (AF). This one is a little vague, but you probably know what I mean: the excesses of care of AF are a huge problem in the real world. Heart-rhythm doctors must help our colleagues treat AF more efficiently…(read more)Â

I’m looking forward to the Heart Rhythm Society’s list of five. Until then, you have mine–as seen from my front row seat to the real world of clinical practice.

JMM

Good sleep and good choices

April 9, 2012 By Dr John

I like to tell my patients that good health, at its root, comes from just three things: good movement, good food, and good sleep. At least these are the three they can control. Good luck and good genes are beyond our control.

On our Easter: The world looks and feels like a different place after a good night sleep. (Now there’s a revelation.) Good sleep mixed with the bright sun, low humidity and cooling winds made everything feel better. The muscles twitched faster, the mind thought more clearly and even the soul felt friendlier. Itâ€™s no wonder that good sleepers live longer. (Iâ€™m going to keep working on that one.)

Even on an Easter Sunday, where the sun amplified the tranquility of the blooming Kentucky flowers, people in cars are still get angry with people on bikes. But you see, on this glorious Easter, we were easily able to deflect the motoristâ€™s rant with, â€œHappy Easterâ€ to youâ€”and ride on. â€¦Is it any wonder there is so much more atrial fib out there; I could not help thinking to myself.

—

On the writing front, I spent some more time working on one of the most promising ideas in Medicine. I love Choosing Wisely because it is for doctors and by doctors. It emphasizes the use of nuance and clinical judgment and in so doing embraces cost-effective care. Each list of five misused interventions shines a bright light on wasteful, nonsensical stuff that happensâ€”in the name of thoroughness–to patients every day.

Naysayers immediately highlight the huge headwinds faced by Choosing Wisely: our current system of compensation rewards doing more while our legal climate penalizes our humanness.

I counter. Fathers and coaches alike often say nothing worth doing comes that easy. Thatâ€™s clearly the case in reforming our system of healthcare.

So what was I working on?

I thought it reasonable to look inward at my field of Heart Rhythm medicine and identify the five most misused or overused interventions in EP. –Choosing Wisely: The Electrophysiology List of Five Donâ€™ts

Stay tuned.

Now it’s back to work.

JMM

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

April 4, 2012 By Dr John

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 costsâ€”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 isâ€¦listen to thisâ€¦

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

Nine medical groupsâ€”with more coming on board soonâ€”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 â€˜epicâ€™ 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 donâ€™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