The “Choosing Wisely” Initiative and Medical Testing

The Choosing Wisely® initiative is a recent partnership between the ABIM (American Board of Internal Medicine Foundation) and Consumer Reports whose aim is to help 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.” A comprehensive (and sometimes comfortably overlapping) list of 45 common tests and procedures was compiled by nine specialty societies representing 374,000 United States physicians. Each list, titled Five Things Physicians and Patients Should Question, identifies five tests or procedures commonly used in each specialty field whose necessity should be questioned and discussed; the lists are intended to stimulate patient-doctor conversations in order to improve care and eliminate unnecessary patient procedures. Essentially, then,  Choosing Wisely is calling for health care providers to limit the use of these procedures where possible. This reduces patient discomfort, saves money and time all the way around, and encourages a more effective use of health care resources.

Sounds easy enough, right?

Well, there are a host of doctors who are balking at the notion of this plan. Dr. Gilbert Ross of the American Council on Science and Health is skeptical of the guidelines, and believes that “…few cases are amenable to such simplistic prospective analyses.” He says, “Also, patients often demand particular tests, and these requests are often difficult to ignore.”

A host of other critics are also wary of this initiative, saying that limiting procedures  is tantamount to ‘healthcare rationing’. “This kind of one-size-fits-all approach can be a real detriment to good care,” says Dr. Eric Topol, chief academic officer of Scripps Health.

There is a contingent of voices around this issue that say the part of the problem is doctors who practice ‘defensive medicine’, wherein doctors order extensive testing to avoid malpractice lawsuits.

There are doctors who strongly disagree and enthusiastically embrace the Choosing Wisely guidelines, believing them to be an idea whose time has come. Dr. Kelly B. Thrasher, a primary care internist right here in Atlanta, is one such proponent. A couple of weeks ago she weighed in with her opinion via the AJC, calling overtesting a ‘red herring’ that distracts from the real issues at hand:

“I recently ordered a CT scan for a healthy 41-year-old male patient complaining of abdominal cramping. He was not experiencing fever, chills, diarrhea or vomiting, but he was losing weight and feeling generally fatigued.

“Many would think a $2,000 CT scan would be an unnecessary test for a patient who likely had a ‘stomach bug.’ But this time it showed multiple areas of infection and diseased intestines due to a previously ruptured colon. He was sent for emergency surgery, which saved his life.

“I did not order this test out of fear of a lawsuit, but rather due to clinical intuition arising out of a strong physician-patient relationship.”

In her declaration of support for Choosing Wisely, she upbraids those special interest groups that would detract from the initiative by claiming that doctors run unnecessary tests to avoid lawsuits. “Defensive medicine’ provides a convenient distraction from the real issues that plague our health care system….costs have not been reliably measured. Existing surveys often rely on narrow surveys of doctors with biased wording and low response rates to bolster their claims.”

 

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