John A Patterson MD, MSPH, FAAFP
First, do no harm!
Second, relieve suffering!
Third, contain cost!
“Primum non nocere”, the historic ethical mantra of medicine, is getting a much-needed 21st century update in the form of the Choosing Wisely Campaign. Twenty five medical specialty societies, representing over 500,000 US physicians, have already created specialty-specific “Top 5 Lists” of tests and procedures that are sometimes overused, can potentially cause harm to patients and may add avoidable cost to our bloated national health care expenditures. In 2013, an additional 25 medical specialty societies will submit their “Top 5 Lists” of tests and procedures after careful review of comparative effectiveness studies.
This campaign began in 2002 with a seminal article in the Archives of Internal Medicine titled “Medical Professionalism in the New Millenium: A Physician Charter.” The AIM editor said of this charter, co-authored by the American Board of Internal Medicine, the American College of Physicians- American Society of Internal Medicine Foundation and the European Foundation of Internal Medicine, “I hope that we will look back upon its publication as a watershed event in medicine.”
The American Board of Internal Medicine and the Council of Medical Specialty Societies jointly sponsor a biennial Putting the Charter into Practice grant to promote adherence to the Physician Charter’s emphasis on putting patients’ interests first and using limited financial resources wisely. In 2009, this grant was awarded to the National Physicians Alliance. The Alliance’s list of guiding principles begins- “We place the best interests of our patients above all others and avoid conflicts of interest and financial entanglements. The health of our patients is our first concern.” The Alliance’s home page displays the mission- “Committed to Advancing the Core Values of the Medical Profession: Service, Integrity, and Advocacy.” Their initial grant project, “Promoting Good Stewardship in Clinical Practice”, asked primary care physicians in internal medicine, family practice and pediatrics to identify a list of 5 overused tests or procedures commonly used in their specialty. These lists were field-tested nationwide and chosen for their basis in evidence from comparative effectiveness studies, their inherent risks to patients and their cost.
This unprecedented campaign has been precipitated by the convergence of several factors, include spiraling health care costs, an unacceptable number of adverse reactions to medical procedures (potentially including lifelong disability and death), growing consumer demand for transparency and involvement in medical decision-making, isolated examples of unethical overuse of medical procedures for monetary gain and, perhaps most importantly, the long-overdue movement toward scientific, evidence-based decisions surrounding appropriate indications for testing, procedures and prescribing. Increasingly, we know when certain tests and procedures are likely to be safe and cost-effective versus when the risk and cost of the procedure may outweigh the benefits.
For too long, the medical liability climate has caused physicians to practice defensive medicine by ordering tests they don’t really need in order to prevent being accused of failure to adequately investigate patient symptoms and diagnose serious disease. Patients have also had a long-standing inflated opinion of the necessity and value of many costly and risky medical tests and procedures. The Choosing Wisely Campaign and its emphasis on Things Physicians and Patients Should Question promote mutually respectful conversations between physicians and patients in order to prevent harm to patients, contain health care costs and enhance the prospect for a safe, effective, ethical and humane medicine.
A partial list of tests and procedures included in this campaign thus far include- antibiotic use for sinusitis, allergy testing, bone-density tests, cancer care at the end of life, pre-operative chest x-rays, use of pain and anemia medications in the presence of kidney disease, dialysis and other management issues in severe kidney disease, indications for initial and follow-up colonoscopies, early elective obstetric delivery, cardiac testing and other tests in cancer patients, Pap smears, pulmonary testing in asthma, testing for Alzheimer disease, imaging for headache, back pain and ovarian cysts and treatment of heartburn, reflux, migraines, erectile dysfunction and peripheral arterial disease.
Grants from the Robert Wood Johnson Foundation (RWJF) will help educate both physicians and patients. Practicing physicians will be educated about the recommendations of these medical societies and helped to communicate these recommendations to their patients. Patients will be educated through an RWJF grant to Consumer Reports, which has developed several initiatives to raise awareness among consumers. These include Best Buy Drugs (emphasizing prescription medications), Care About Your Care (to reduce hospital readmissions), Choosing Wisely Campaign (targeting safe, appropriate use of overused and potentially harmful procedures), Engage with Health (aimed at businesses and their employees), High Value Care (an extension of the American College of Physicians’ High Value, Cost-Conscious Care Initiative), and Physician Ratings (in collaboration with the RWJF’s Aligning Forces for Quality).
Consumer Reports’ newest campaign is Preventing Overdiagnosis (Winding Back the Harms of Too Much Medicine). It will be launched in September 2013. It focuses on the routine use of screening tests and the early detection of conditions that may never cause clinically significant disease.
The Choosing Wisely Campaign and its Things Physicians and Patients Should Question are helping patients, medical societies and consumer groups collaborate in new ways. They will help us all promote good stewardship in medicine by avoiding harm, containing costs and improving doctor-patient communication that characterizes the therapeutic relationship so essential to good medicine.
ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002 Feb;136(3):243-246
Good Stewardship Working Group. The “top 5” lists in primary care: Meeting the responsibility of professionalism. Arch Intern Med. 2011 Aug 8;171(15):1385-90
National Physicians Alliance http://npalliance.org
Choosing Wisely Campaign http://www.choosingwisely.org
Things Physicians and Patients Should Question http://www.choosingwisely.org/doctor-patient-lists/
Consumer Reports Campaigns http://consumerhealthchoices.org/campaigns/
About the Author-
Dr Patterson is past president of the Kentucky Academy of Family Physicians and is board certified in family medicine and integrative holistic medicine. He is on the family practice faculty at the University of Kentucky College of Medicine and the University of Louisville School of Medicine, Saybrook University’s School of Mind Body Medicine (San Francisco) and the Center for Mind Body Medicine (Washington, DC). He operates the Mind Body Studio in Lexington, where he offers integrative medicine consultations. He can be reached through his website at www.mindbodystudio.org