Dr. Cassel Sets Out The Mission of the Choosing Wisely Initiative

Christine K. Cassel

Posted 4/5/12 on the ABIM Foundation Medical Professionalism Blog

As we all know, this is a time of great challenge and introspection in our health care system. Not just in terms of health reform – although that has been the catalyst for several critically important conversations over the last two years. I’m referring to a broader reexamination of how we deliver care in America and what physicians, working with their patients, can do to ensure the highest-quality care.

This is an important conversation for us to have, and in a polarizing political environment, it can be difficult for rational discourse. Waste, overuse, accountability – these are simple terms that belie the complex underpinnings of our health care system. While some might be tempted to pick a particular phrase as the launching point for this rhetoric, the facts driving our work speak for themselves. And what they show is that despite significant investment in our health care system, it does not deliver the quality or value we would expect, and that patients deserve.

Consider that some estimates have shown that as much as thirty percent of the care delivered in the United States today is duplicative or unnecessary and provides no benefit. If current trends remain unchanged, the Centers for Medicare & Medicaid Services projects that health care spending will reach $4.6 trillion and account for 19.8 percent of the nation’s gross domestic product by 2020.

But while it is important to note there is wasteful spending in health care, I think is more important that we focus on the causes of that waste—namely overused tests and procedures that are not supported by evidence and don’t improve patient outcomes.

There is growing recognition among the health care community of the importance of enhancing patient-centered care to improve outcomes. To make good on this commitment, we will need better information about what interventions truly benefit patients, and resources to support rational discussions that more care is not always better care.

That’s what the ABIM Foundation, along with its partners, hopes to achieve through the Choosing Wisely® campaign. It’s about physicians and patients having conversations – real, informed conversations, about making wise choices about their care and avoiding unnecessary tests or procedures not supported by evidence.

As physicians, we need to recognize the importance of these conversations with our patients, and make sure the right patient gets the right care at the right time. Sometimes this means saying no to a request for a particular test or treatment if it is not supported by evidence or guidelines. As trusted voices in our health care system, it is our responsibility to our patients to make sure they get only the care they need and that from which they will benefit.

Equally critical in the conversation are our patients. To be engaged partners in their own care, patients need better information about what tests and treatments are truly necessary for their situation. We know patients are seeking this information already through mass media and online. As physicians, it is our responsibility to help them understand their treatment options and make wise choices. We want to have conversations to help them better understand what the “right” care is based on their particular preferences about the latest evidence and treatment options, versus just fulfilling requests for care that is not in their best interest.

That’s why the leadership of the specialty societies is so important. The lists they’ve created can help serve as a starting point for these conversations about avoiding unnecessary care. Because while it may seem like physicians are in the driver’s seat for these decisions, research shows many physicians feel compelled to accommodate a patient’s requests for tests or procedures, even when they don’t think it will be beneficial.

We can see the early roots of Choosing Wisely in Medical Professionalism in the New Millennium: A Physician Charter, which was published ten years ago. Co-authored by the ABIM Foundation, the ACP Foundation and the European Federation of Internal Medicine, the Charter articulates the professional responsibilities of physicians and underscores a commitment to improve quality and access to care, and advocates for a just distribution of finite health care resources. This commitment specifically calls on physicians to be responsible for the appropriate allocation of resources and to carefully avoid unnecessary tests and procedures.

More recently we’ve heard the wise words of health care ethicist Howard Brody, who proposed that physicians take the lead in identifying waste to be eliminated by creating “Top 5” lists of egregious causes of waste in their fields. Taking this idea another step, the ABIM Foundation supported the National Physicians Alliance in the development of lists of five things that physicians in internal medicine, family medicine and pediatrics should question in their practice.

We are pleased all of these groups participating in Choosing Wisely recognized the opportunity to significantly broaden the scope of this concept and engage practicing physicians in improving the health of their patients by joining the effort.

The nine lists developed by these organizations – totaling forty-five recommendations – cover what the societies identified as the most commonly used but not always necessary tests and procedures in each field of practice. They have the potential to make a significant impact on patient care, safety and quality.

Reading over what has been produced in the last year, I commend them for taking this unprecedented step. Each has shown tremendous leadership in starting this important conversation and each deserves recognition.

Today’s news is very exciting, and we feel it is just the beginning. We are pleased that eight new major national specialty and physician organizations have joined Choosing Wisely and will be unveiling their lists of “Five Things Physicians and Patients Should Question” in the fall. And through Consumer Reports and their communications collaborators, millions of patients will receive the tools and resources they need to have to talk with their physicians about using the most care most appropriate for their individual situation.

Choosing Wisely is about more than just the lists. It’s about a serious conversation between physicians and their patients to eliminate unnecessary tests and procedures and avoid harm. It is medical professionalism in action.

I invite you to learn more at www.choosingwisely.org.

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