John A. Patterson MD, MSPH, FAAFP
First do no harm!
This historic ethical mantra of medicine is getting a much-needed 21st century update in the form of the Choosing Wisely Campaign. Twenty six medical specialty societies, representing over 500,000 US physicians, have created specialty-specific lists of procedures that are sometimes overused, may add avoidable cost to health care and can potentially cause harm. All medical societies have been asked to participate. Those that have thus far contributed to Things Physicians and Patients Should Question include the specialties of allergy, anesthesiology, cardiology, colorectal surgery, critical care medicine, dermatology, emergency medicine, endocrinology, family practice, gastroenterology, geriatrics, hematology, hospice and palliative care, hospital medicine, internal medicine, long-term care, ophthalmology, obstetrics and gynecology, oncology, orthopedics, otolaryngology, nephrology, neurology, pathology, pediatrics, psychiatry, radiology, rheumatology, thoracic surgery, urology and vascular medicine.
This unprecedented campaign has been precipitated by the convergence of several factors. These factors include spiraling health care costs, an unacceptable number of adverse reactions to medical procedures (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 and prescribing. Increasingly, we know when certain tests and procedures are likely to be safe and effective versus when the risk of the procedure may outweigh the benefits.
For too long, physicians have felt compelled to practice ‘defensive medicine’ by ordering excessive numbers of tests to prevent being accused of failure to adequately investigate patient symptoms. Patients have also had a long-standing inflated opinion of the necessity and value of 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, when to have an initial or follow-up screening colonoscopy, scheduling early delivery in pregnancy, cardiac testing and tests in cancer patients, Pap smears, breathing tests in asthma, testing for Alzheimer disease, treating heartburn, reflux, migraines, erectile dysfunction and blocked leg arteries and x-rays for headache, back pain and ovarian cysts.
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. There is presently a heated debate in medical and consumer circles over the recent estimates that as much as a third of breast cancers are ‘overdiagnosed.’ This refers to cancers being diagnosed that are unlikely to ever grow or spread sufficiently to cause disease and illness.
The physical, emotional, social, financial and spiritual stresses surrounding cancer in general and breast cancer in particular make this conversation one of today’s most important, poignant and challenging. 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 avoid harm, contain costs and improve the doctor-patient communication that characterizes the therapeutic relationship so essential to good medicine.
Choosing Wisely Campaign http://www.choosingwisely.org
Consumer Reports Campaigns http://consumerhealthchoices.org/campaigns/About the
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