Reducing harm: When doing less is enough

 

Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.¹

In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.

“What we’re trying to do is avoid harm,” said Daniel Wolfson, executive vice president and chief operating officer of ABIM. “That harm can be clinical, physical, psychological, and financial. That’s what we’re trying to reduce.”

Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
 

Choosing Wisely’s successes

In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.

“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”

To help communicate these messages to patients, Choosing Wisely partnered early on with Consumer Reports, and hospitalists count that partnership as another success. By producing reports, brochures, and videos that translate medical language into layman’s terms and offer patients specific advice about talking with their provider – all under the trusted Consumer Reports name – the company provides tools for physicians to make these conversations transpire more efficiently.

The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.

Challenges remain

While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.

“It’s part of what makes that conversation with the patient so difficult from the provider’s side – that idea that taking away care from them can actually be better for them,” said Alexander Mainor, JD, MPH, research project coordinator at the Dartmouth Institute, which published “Physician Perceptions of Choosing Wisely and Drivers of Overuse.”²

“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”

Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”

Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”

Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.

“That’s the patient-centered part of this process that I think is very important and is always a challenge,” said Harry Cho, MD, FACP, director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York. “Doctors need to understand patients, too. Their thought may be, ‘I want more tests so that the doctor can make a better decision.’ Understanding where that knowledge gap is and what we need to do in terms of education and reaching out to patients and making the decision together, I think, will be very helpful.”
 

 

The road ahead

The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.

“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”

Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”

Perhaps these additional conversations will start to happen as value becomes a more defined career path in hospital medicine and as the ideas behind Choosing Wisely continue to move to the forefront.

“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”

In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.

“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
 

References

1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.

2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.

 

Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.¹

In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.

“What we’re trying to do is avoid harm,” said Daniel Wolfson, executive vice president and chief operating officer of ABIM. “That harm can be clinical, physical, psychological, and financial. That’s what we’re trying to reduce.”

Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
 

Choosing Wisely’s successes

In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.

“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”

To help communicate these messages to patients, Choosing Wisely partnered early on with Consumer Reports, and hospitalists count that partnership as another success. By producing reports, brochures, and videos that translate medical language into layman’s terms and offer patients specific advice about talking with their provider – all under the trusted Consumer Reports name – the company provides tools for physicians to make these conversations transpire more efficiently.

The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.

Challenges remain

While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.

“It’s part of what makes that conversation with the patient so difficult from the provider’s side – that idea that taking away care from them can actually be better for them,” said Alexander Mainor, JD, MPH, research project coordinator at the Dartmouth Institute, which published “Physician Perceptions of Choosing Wisely and Drivers of Overuse.”²

“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”

Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”

Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”

Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.

“That’s the patient-centered part of this process that I think is very important and is always a challenge,” said Harry Cho, MD, FACP, director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York. “Doctors need to understand patients, too. Their thought may be, ‘I want more tests so that the doctor can make a better decision.’ Understanding where that knowledge gap is and what we need to do in terms of education and reaching out to patients and making the decision together, I think, will be very helpful.”
 

 

The road ahead

The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.

“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”

Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”

Perhaps these additional conversations will start to happen as value becomes a more defined career path in hospital medicine and as the ideas behind Choosing Wisely continue to move to the forefront.

“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”

In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.

“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
 

References

1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.

2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.

 

Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.¹

In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.

“What we’re trying to do is avoid harm,” said Daniel Wolfson, executive vice president and chief operating officer of ABIM. “That harm can be clinical, physical, psychological, and financial. That’s what we’re trying to reduce.”

Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
 

Choosing Wisely’s successes

In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.

“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”

To help communicate these messages to patients, Choosing Wisely partnered early on with Consumer Reports, and hospitalists count that partnership as another success. By producing reports, brochures, and videos that translate medical language into layman’s terms and offer patients specific advice about talking with their provider – all under the trusted Consumer Reports name – the company provides tools for physicians to make these conversations transpire more efficiently.

The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.

Challenges remain

While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.

“It’s part of what makes that conversation with the patient so difficult from the provider’s side – that idea that taking away care from them can actually be better for them,” said Alexander Mainor, JD, MPH, research project coordinator at the Dartmouth Institute, which published “Physician Perceptions of Choosing Wisely and Drivers of Overuse.”²

“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”

Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”

Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”

Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.

“That’s the patient-centered part of this process that I think is very important and is always a challenge,” said Harry Cho, MD, FACP, director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York. “Doctors need to understand patients, too. Their thought may be, ‘I want more tests so that the doctor can make a better decision.’ Understanding where that knowledge gap is and what we need to do in terms of education and reaching out to patients and making the decision together, I think, will be very helpful.”
 

 

The road ahead

The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.

“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”

Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”

Perhaps these additional conversations will start to happen as value becomes a more defined career path in hospital medicine and as the ideas behind Choosing Wisely continue to move to the forefront.

“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”

In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.

“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
 

References

1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.

2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.