Promoting Good Stewardship in Medicine

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. Dozens of medical specialty societies, representing the majority of US physicians, have 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. These “Top 5 Lists” of avoidable tests and procedures are based on a 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 Annals of Internal Medicine 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”Top 5 Lists” of the Choosing Wisely Campaign emphasize putting patients’ interests first, using limited financial resources wisely and are 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, including 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 of dubious merit 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 promotes 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 early in this campaign 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) have helped educate both physicians and patients. Practicing physicians learn about the recommendations of  medical societies and help communicate these recommendations to their patients. Consumer Reports consistently raises awareness among the consuming public..

The Choosing Wisely Campaign is helping patients, medical societies and consumer groups collaborate in new ways. This 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

Choosing Wisely Campaign

Consumer Reports Campaigns

About the Author-
Dr Patterson is past president of the Kentucky Academy of Family Physicians and is certified in family medicine, integrative holistic medicine, mind body medicine, mindfulness-based stress reduction (MBSR), Mindful Practice in Medicine, yoga therapy and physician coaching. He is on the faculty of Saybrook College of Integrative Medicine and Health Sciences (Pasadena) and the Center for Mind Body Medicine (Washington, DC). He teaches stress management for the University of Kentucky Health and Wellness Program and operates the Mind Body Studio in Lexington, where he offers integrative medicine consultations and group classes. He can be reached through his website at