Choosing Wisely or Vicely

Bradley Flansbaum

Posted 4/29/12 on The Hospitalist Leader

The press gave the Choosing Wisely initiative, unveiled several weeks ago, a great deal of attention.  Briefly, the ABIM foundation collaborated with Consumer Reports to produce Top 5 lists from nine specialty societies to identify “five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.”  It is a first step to engage patients and physicians in the shapeless “national conversation” on (sensibly) rationing  that everyone speaks of, but never hears.  I write about it now, not just because this process is inevitable—which it is, but because the Society of Hospital Medicine is amongst the next group of eight to offer up recommendations.

Voluntary guidelines generally do not command attention.  One envisions this list of 2500+ much the same way we view our bedroom walk in closets.  The filled shoeboxes of yesteryear are there, but we will not open or utilize their contents again.  Knowing they are near though allows us to sleep better, a token consolation, but alas, they are memories.

Given the thrust behind this effort, and my personal interest in this subject, I wished to assess their potential as practice altering tools.  To do so, I spent a number of hours incorporating them into my team’s daily teaching rounds at the hospital the past two weeks.

Over nine days, we spent 20-30 minutes reviewing each one, and commented on their practical nature and utility as instruments of change for providers.  My team consisted of two third-year medical students (both “considering” primary care), two preliminary interns (radiology, radiation oncology), and a second year resident.  I documented their conclusions further below, but first my assessment.

To restate, the passion underlying this endeavor, as eloquently stated in this April 25 interview, is obvious.  The folks behind Choosing Wisely are serious.  However, without more consideration on provider uptake, this effort may well be another shoebox disappointment.  I have given this a good deal of thought, and here is why:

1.  Hard stops and ambiguity: See these two endorsements offered up by the American Society of Nephrology as contrasts:

The first is an evidence-based affair, with an “if x, then y” effect.  Moreover, this is low hanging fruit that conforms with Medicare payment policy, and is hardly a “carrot” approach.  If the entire list or medicine in general operated similarly, we would not need a national conversation or this effort.  We could non-abrasively regulate our way to fiscal sanity.

Contrast that with the second recommendation, which relies on physician assessment of survival—that doctors typically fix based on their individual approach to care.  If a prediction score for living 5-10 additional years was bundled within the rule, it might be practical and would appropriately redirect physician decision-making.  But how is this immediately helpful to doctors caring for hemodialysis patients, who by definition have suboptimal longevity?

Unfortunately, many of the rules, also like the one below, similarly rely on varying physician judgment:

One doctor might describe performance status (“she was fine three weeks ago before the pneumonia and ventilator failure”) differently than another; “strong” evidence may be in the eye of the beholder; or a patient like this is, a) one in which most oncologists would not treat, b) is at a point where much of the treatment intensity has already occurred, and c) gets at only a small fraction of the oncologic treatment overuse or misuse that needs targeting.

The hard stuff requires more than suggestions.  When we base care on interpretation and judgement, rules like above may evolve physicians only somewhat into more confident stewards.

2. False equivalency between professional societies: As each organization steps up and offer tests or treatments to improve care delivery, the list grows and conveys a shared burden amongst participants.  However, some contributions are weightier; some subspecialties are more bearing due to the organs or diseases they treat; and some have more evidence to guide their submissions.  See below:

Helpful perhaps, but these are not impactful.   Difficult as it might be, we must ask greater sacrifice of outsized organizations–either due to their mass, or more importantly, their resource sway.

Here is a rough estimate:

Internal medicine expends a great deal, but not in excess.  Conversely, radiation oncology overspends, but comprises a smaller fraction of the entire sum consumed.

3.  Attribution: My preliminary intern entering radiology was quick to ask, “why should the radiologist bear the burden of tests ordered by others?’  She is correct.  Without denoting mission ownership, recommendations will not materialize into action.    It is not enough for an organization to state that test “x” is needless, but they must also take possession of the results.  Without that commitment, business will spin in a blameless circle.

Under whose province does this accountability rest?

4. Erroneous Impression: Akin to #2, and I understand this is a first attempt at culture change, reviewing most recommendations, few are game changers and will not yield large savings.  As an example, see this table from a separate publication and the projected surpluses resulting from practice modifications:

Statin substitution is real money, as is imaging for back pain, but most interventions have minor impact.  My point is long lists do not equate to correspondingly large dollar efficiencies.  The real grist is in ethical, costly, uncertain treatment choices–which these campaigns will not effect.  I await the American Academy of Hospice and Palliative Medicine and their suggestions, but I can envision the proposals and the burden of implementing them successfully.  This is the wrong venue for that type of delivery alteration, but unfortunately, that is precisely where we need to aim the arrow.

5. Conflicting message:  For payers, it’s about cost control, for patients it’s about harm versus benefit (which sometimes translates to a misplaced “do more,” because that must be better), and for docs it’s about defensive practice or culpability or income loss.  I am generalizing, but there is no projected “front and center” theme as to why this campaign is vital for our healthcare system.  Each party hews to its own vested interest, and this is exceedingly difficult to overcome.

The answer is, it is about the greater good.  That might be too buoyant for most, but the barriers are not just the inability of patient and provider to converse, but those above-mentioned interests, and the tensions they create within each entrusted party.  The sum of these invisible tensions generate gridlock far in excess of the individual parts.  If we do not address those, no glowing conversation will ever occur.

This recommendation embodies a bit of that sentiment:

In closing, I might take heat for criticizing a noble campaign.  It is noble.  I also think it might fizzle, at least on the provider end.  Maybe its my bias, but unless sticks (internalizing costs, regulated transparency) are in the equation, carrots won’t likely succeed–at least for most organizations.  I have little faith in my brethren, but it has more to do with human nature—folks just do what they do, regardless of their calling, than malice towards the system or change.

What the ABIM foundation got right is patient engagement, especially via the inclusion of Consumer Reports and AARP.  Consumers Union has brand recognition and credibility beyond reproach, and the AARP has unparalleled scope.  However, they both must relentlessly educate and encourage proactive behaviors to promote more discussion amongst their members.  The campaign also must be durable over years, and remain at the fore of their health promotion efforts.

As an aside, both miss a key demographic: younger and less affluent folks.  Thus, additional publications or channels are necessary, and I would hope that insurance exchanges, inevitable with or without reform, will embrace opt-ins (or opt-outs) for information as patients enroll.  I also fancied these brochures released recently by the American College of Physicians.  They are fantastic and what patient instruction should be:  factual, concrete, and easily understood.  If you have diabetes or lower back pain, there is no ambiguity as to what you need.  All should read them (and crib their format), as the ACP did their homework.  They just need a persistent, mainstream channel for distribution.  Calling Dr. Oz.

And about my team, you might be curious of their impressions.  I was surprised. Maybe they are too optimistic, or me too cynical, who knows, but if their outlook is indicative of the future, we are in secure hands.  However, their enthusiasm probably stems from the applied realm they have yet to see, and the chasm they still must cross.  It is called the real-world.  Take a peek:

BONUS #1: I am using this iPhone app to determine decibel strength on our wards during quiet hours.  Errant noise is a huge patient satisfaction issue nationally, and this is a helpful tool and works great (Hint: 60 dB is about right). I have no vendor affiliation.

BONUS #2: A tribute to my former program director, and boss…and now great friend. Look up integrity and honor in the dictionary and you will see his face.  They do not come better.

BONUS #3: Great book, not just about presidential history, but how the medical establishment helped kill our twentieth.

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