The Choosing Wisely® campaign was launched in 2012 as initiative of the ABIM Foundation, (American Board of Internal Medicine Foundation.) to encourage physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances, can cause harm.
To implement the Choosing Wisely® program, national organizations representing medical specialists were asked to identify five tests or procedures commonly used in their field, whose necessity should be questioned. Many of these organizations came up with responsible, logical choices.
On the other hand, according to an article in the New England Journal of Medicine, some specialist groups skirted around the issue suggesting minor tests and procedures be eliminated from their recommendations. For example, The American Academy of Orthopedic Surgeons, named use of an over-the-counter supplement as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure, but no major procedures that represent the major source of their income.
Among the 130 tests, procedures and treatments that the Choosing Wisely® task force ultimately questioned are: Allergy tests; Use of antibiotics; Bone density tests; When to choose cancer treatment at the end of life; Pain Relievers for kidney and heart disease; Colonoscopies; EKGs, exercise stress tests, and echocardiogram; When to administer drugs for chemotherapy; Heart imaging and Heart tests delivered on a wide basis before surgery; Hormone Replacement Therapy; Imaging and tumor markers for breast cancer; Various tests for prostate cancer; Imaging tests for lower-back pain; Pap tests and other gynecological procedures; Spirometers for asthma; Brain scans to test for Alzheimer’s disease, and many others.
The question is whether or not this campaign, two years out, has yet managed to identify and eliminate unnecessary tests and procedures that harm quality of care, generate unnecessary side effects in patients and add significantly to the nation’s tab for medical care. The answer is, not really.
Changes in practice patterns and patient expectations that have been shaped and reinforced by habitual overuse of health care over decades are difficult to implement. They require joint patient/provider decisions about commonly used tests and procedures, which have to be determined by an individual patient’s specific situation and not by pre-established standards of care that are no longer valid. Ideally, this concept has patients and their health care providers choosing treatment that does not duplicate tests or procedures already experienced; has proven to be necessary for a long-term better outcome; is supported by evidence and does no harm.
There is hope. We now know that when it comes to health care, more is not necessarily better. Until recently, the financial incentives for both doctors and patients have been weighted towards over-treatment and against shared and informed decisions, With the health care landscape changing, as higher percentages of the cost of care is coming out of the healthcare consumer’s pocketbook, patients will not be as quick to demand tests and treatments. Additionally, as we transition from a fee for service model of care to bulk payments to physicians, diagnostic and treatment decisions will be based on quality-conscious, patient-centered communication, that is supported with clear evidence-based guidelines that provide the rationale for treatment choices, rather common practice that has gone on for years.