The patient-physician relationship is a partnership that requires a two-sided dialogue in order to decide on the most effective treatment options. The Choosing Wisely® campaign from the American Board of Internal Medicine (ABIM) aims to promote conversations between patients and physicians to choose evidence-supported, low-risk, necessary care that is not duplicative of other tests or procedures already completed.
Physicians want their patients to be well informed because it only makes their partnership in shared decision-making stronger. The goal of Choosing Wisely is not only to foster a conversation between physician and patient that helps them discuss when a test or procedure might not provide benefit to a particular patient but also to give patients the courage to question why a test or procedure is being done and what might be the potential benefits or harm.
The campaign gathered more than 70 professional societies to create lists of “Things Providers and Patients Should Question.” The recommendations cover tests, treatments and procedures commonly encountered in a variety of specialties, including:
- The American Society for Metabolic and Bariatric Surgery suggests avoiding routine postoperative antibiotics because extending the duration of prophylactic antibiotics may increase the risk of superinfection with Clostridium difficile and the development of antimicrobial resistance.
- The American Urogynecologic Society suggests avoiding the removal of ovaries at hysterectomy in pre-menopausal women with normal cancer risk because there is evidence from observational studies that surgical menopause may negatively impact cardiovascular health and all-cause mortality.
- The American Medical Society for Sports Medicine suggests that physicians avoid recommending knee arthroscopy as initial/management for patients with degenerative meniscal tears and no mechanical symptoms because degenerative meniscal tears may respond to non-operative treatments.
The examples in the lists offer comprehensive guidance that can help physicians avoid procedures and tests that may not be necessary, and each bit of advice is supported by evidence detailed in the lists.
How to use Choosing Wisely in your medical practice
Though the lists are thorough and hold valuable, physician-authored recommendations, actively using them in practice means a slight change in culture and procedure.
Engage your physicians and medical staff
Centering the conversation around patient benefits will resonate more than discussions of waste and cost reduction. Pilot Choosing Wisely in one disease area or with one diagnosis first and see how it works before expanding.
The recommendations are conversation starters, not mandates. As always, medical decision-making is based on the patient’s best interest. Remember, unique circumstances for individual patients may mean deviating from the recommendations.
Engage your patients
The success of these materials depends on your ability to involve patients in a dialogue about the purpose of tests, treatments and procedures so they have a clear understanding of what’s necessary, that’s not and what could cause them harm.
Initiate the dialogue by demonstrating empathy for your patient’s desires, needs and concerns—their cues will tell you when they are ready for you to introduce decision aids or patient education, which can be found in the module.
Establish an implementation plan
Implementation could take the form of a formal educational program, as well as checklists and protocols to help standardize the new processes. You may even choose to work with your IT department to embed Choosing Wisely recommendations into clinical decision support tools within the electronic health record (EHR).
However, remember that the recommendations are intended to be starting points for conversation, not rigidly imposed guidelines and they should be treated as such if embedded in the EHR.
To educate your practice, consider using the physician communication modules from Choosing Wisely. Physicians and medical staff can watch the videos and work through the modules during a scheduled team meeting.
Use data to understand and improve performance
Tracking and reporting will help determine the effectiveness Choosing Wisely is having on your practice. Sharing peer comparison data over time is one of the strongest interventions available for change, and should be part of any strategy.
Ideas for improvement could come from reviewing data in your EHR, pre-printed order sheets, standing orders or ideas from your team members. Target the tests you suspect may be overused, inconsistently used or harmful to patients.
Consider starting with clinical areas where the frequency of overuse is highest, such as lab testing or imaging. Another target area is any area where large amounts of variation exist. Review common tests and treatments by physician, establish a baseline and then compare and contrast to identify variability.
There are seven new modules now available from the AMA’s STEPS Forward™ collection, bringing the total number of practice improvement strategies to 42, thanks to a grant from and collaboration with the Transforming Clinical Practices Initiative.