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Choosing Wisely: 5 Years Into Uphill Battle To Reduce Medical Over-Treatment

(Gerald Herbert/AP)MoreCloseclosemore
(Gerald Herbert/AP)

The Choosing Wisely campaign seemed satisfyingly simple when it launched five years ago. Doctors identified dozens of tests and treatments that could harm patients, or at least cost them money they didn’t need to spend: antibiotics prescribed for the common cold; a routine chest X-ray before surgery; an MRI for a garden-variety headache.

The clear message to fellow doctors and patients: Avoid these things. (Wondering about something specific? The full list for patients is here, from foot pain to breast cancer.)

The American Board of Internal Medicine Foundation and its partners published the list, along with questions patients could ask to be sure they were getting the most appropriate care.

The Choosing Wisely list has grown to hundreds of not-so-wise tests and treatments, and the foundation is working with health care systems around the country to find ways to change doctors' behavior, recognizing that old habits die hard.

But a recent article in Health Affairs compared surveys of doctors in 2014 and 2017 and found that the campaign has been slow to gain traction, with little change in awareness among doctors and a small increase in those who said they found it difficult to talk to patients about avoiding low-value care.

Daniel Wolfson, executive vice president of the ABIM Foundation, says his organization knows that decades of overuse in health care can’t be reversed just by issuing a set of proclamations, though he sees pockets of promise.

Perhaps most promising is this point he made: Choosing Wisely’s message is now part of medical school training. Every year, more doctors are entering the workforce who think differently.

In this edited conversation, Wolfson talks about the intractability of the problem and the role patients can play.

The challenge of over-treatment gets at something that is deep in human nature, and that is how uncomfortable we all are with uncertainty.

And so are doctors.

You’re up against something big.

Uncertainty drives both patients and physicians to do more, because they want to be totally certain about a diagnosis, and you can’t blame them. But sometimes it’s just not necessary, because the diagnosis is pretty well established. Over-testing can lead to harm, and it can lead to discoveries of things that are not important for our health – we call them incidentals. It leads to more testing that ultimately has no consequence for a person’s health.

So, doing less is better in certain cases?

It’s not always better, but sometimes it is better to do less. Every test and procedure comes with a risk. You don’t want to do things that are putting people unnecessarily at risk.

That message — do less — isn’t something many people are accustomed to hearing from their doctor. How do you explain it to someone who has come to a doctor’s office hoping to be told what they can do to feel better?

Well, I’m not a doctor, so let me start there. But what I want most from a doctor is to be listened to and to [have the doctor] explain, as carefully as you can in language I can understand, about my condition. It’s often said that patients are demanding of tests and procedures. What I think more is that patients want to be listened to and hear their options and have a discussion about what direction to go in.

What can patients do to encourage those conversations?

We put a lot of things on our patients in the time that they are the most vulnerable. I don’t think that this should all rest on the shoulders of the patient. It needs to be shared by the physician. There are things that patients can do. There are the five questions that a patient can ask about their care [starting with, 'Do I really need this test or procedure?']

What’s difficult for a patient is when a physician is doing something that the patient doesn’t think is appropriate and the patient is trying to talk them out of it. I’ll give you an example: I had two detached retinas and two cataract operations. For each one, I had to get an EKG. I’m a runner. A 15-minute operation under sedation of a sleeping pill -- I don’t need an EKG…. [The anesthesiologist] had a protocol that he didn’t want to break, and I couldn’t talk him out of it. That’s the position I don’t want to put patients in. What I want for patients is, at least, coming to a shared decision with a physician about what should be done, where there’s agreement between both patient and physician. I think we can get there.

In 2017, 46 percent of doctors surveyed said it had become harder in recent years to have those conversations, up slightly from 2014. Why?

I don’t have a good answer for that. When physicians are prepared to have those conversations and they have the skills and the attitudes to do those conversations, they’re in fact easier.

It’s going to take some more time. We’ve been building up overuse for the last 30 years, and I think it's magical thinking if we think in five years we would solve this problem.

The Trump administration has begun rolling back some incentive programs meant to reward doctors for keeping patients healthy rather than paying them for every test or treatment. Those programs are seen as key to curbing over-treatment. Are you concerned about the effects on your campaign?

Choosing Wisely came in right at the enactment of the Affordable Care Act. It was the right message, it was the right messenger, and it was the right time. If it’s now not the right time and we’re going to go back to fee-for-service and not talking about value and we don’t care about the sustainability of the health care system — we have no relevance. We’ll be totally marginalized. I’m hopeful that all of those things will be in place and we’ll be there, on the ground, working to reduce unnecessary care.

What is the obligation of physicians in the 21st century? One of them is to be good stewards of resources. It’s not optional. It’s a part of being in the profession. When you raise it to that level, it makes physicians really want to think about how to do this to fulfill their social contract with society.

Chelsea Conaboy is a freelancer who writes often about health care. Find her at chelseaconaboy.com and on Twitter @cconaboy.

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