Choosing Wisely

Logo for the campaign

Choosing Wisely is a United States-based health educational campaign, led by the ABIM Foundation. It seeks to improve doctor–patient relationships and promote patient-centered care by informing patients and physicians about overutilization of medical resources.

The campaign addresses the problem of patients receiving unnecessary health treatment, reasoning that this results in poor outcomes for the patient and could create significant waste in the United States healthcare system. To conduct the campaign, a coordinator from ABIM Foundation asks medical specialty professional organizations to make five recommendations for preventing overuse of a treatment in their field. Distributors then share this information with community groups nationwide, and the medical specialty societies disseminate it to their members. The intent is that patients and doctors will discuss the recommendations in these lists, believing that if patients and doctors communicate with each other more effectively when making health decisions patients will have better outcomes and the medical system itself will benefit.

The campaign follows a history of proposals for both increasing doctor-patient communication and reducing waste in health care. Most commentators confirm the existence of avoidable waste in the health care system. Proponents of the campaign say that it is a uniquely broad and much-needed effort.

Motivation

The Choosing Wisely campaign presents the following background and narrative to explain its motivation: The cost of health care in the United States is not affordable for many people or the nation. According to the Organisation for Economic Co-operation and Development, the United States spends more than 20 times what comparable countries spend per person on healthcare. Some analysts have proposed that identifying and eliminating waste in health care would result in significant savings for the health care system and reduced costs for employers. A 2005 study by the National Academy of Sciences argued that 30% of the health care spending in the United States was wasteful and subsequent research has supported this finding. Some reports indicate that countries comparable to the United States are able to provide better health care to more people while consuming fewer medical resources. Reducing the cost of health care would make it accessible to more people.

One of the identified causes of the waste in the health care system is a lack of communication between doctors and patients. The decisions of physicians account for most of a patient's expenses, yet physicians work under various pressures including limited time to talk with patients and review their information. Patients sometimes make requests for treatment against their doctor's advice in cases where more effective choices would be made if doctors had time to consult expert medical opinion.

The campaign has been described as an attempt to encourage doctors and patients to recognize the illusion of control or "therapeutic illusion" in choices to use treatments which have a basis outside of evidence-based medicine.

History

Christine K. Cassel explains the Choosing Wisely campaign

In 2002 the ABIM Foundation published Medical professionalism in the new millennium: a Physician Charter. The charter states that physicians have a responsibility to promote health equity when some health resources are scarce. As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members. In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists". Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.

Continuing this project, Choosing Wisely was created to organise the creation of more "lists of five" and their distribution to more physicians and patients. Physicians participate by joining their specialty society in identifying practices which their field may overuse, and engaging their patients in conversations aimed at reducing unnecessary care, and hence reduce healthcare costs. Each recommendation in the program must have the support of clinical guidelines, evidence, or expert opinion.

Campaign

To participate in Choosing Wisely, each society developed list of five tests, treatments, or services which that specialty commonly overuses. The society shares this information with their members, as well as organizations who can publicize to local community groups, and in each community patients and doctors can consider the information as they like. As of February 2013, there were 135 recommendations targeting a range of procedures to either question or to avoid without special consideration.

Examples

Some examples of the information shared in Choosing Wisely include the following:

• Acknowledge that physicians are increasing their use of diagnostic procedures without a proportional increase in patient outcomes. Consider the effects of overuse of diagnostic services.
• Physicians overuse radiography services. In many cases this fails to improve patient outcomes. This also subjects patients to unnecessary ionizing radiation and the possibility of further unnecessary testing.
• Before the 39th week of pregnancy, doctors should not perform a Caesarean section or induce labor unless medically necessary.

Difficulties

The Choosing Wisely campaign identifies the following difficulties in achieving its goals:

• In communicating with patients a major challenge in the campaign is the problem inherent in patient-centered care of giving patients some basis for understanding how to make decisions about their health care. Many recommendations in the campaign require clinical education to understand fully. Also many patients tend to follow the recommendations of their physicians without question, even if they have questions.
• The United States medical system is designed so that most doctors get paid when they provide treatment and not paid when they do not recommend treatment. This system creates a pattern for doctors to recommend more treatment.
• Critics tend to view efforts to reduce medical services as "healthcare rationing in the United States". Since doctors do not want to be seen as withholding care, they are hesitant to change established behavior in any way that lessens the amount of treatment they order. Doctors say that they often feel pressure to engage in defensive medicine by conducting extra testing to avoid lawsuits.

Reception

Many of the leading medical societies in the United States are participating in the campaign as partners and in that way have demonstrated their support.

The New York Times said that the campaign was likely to "alter treatment standards in hospitals and doctors' offices nationwide" and one of their opinion writers found that many tests were unnecessary. CBS News said that "the evidence is on the initiative's side." USA Today noted that the campaign was "a rare coordinated effort among multiple medical societies". A Vogue reviewer said that Choosing Wisely was a counter to defensive medicine practices by doctors and a counter to patients who demand extra procedures without understanding the risks involved. In February 2013 the Robert Wood Johnson Foundation provided USD $2.5 million in funding for the campaign, saying that the foundation wanted to "help increase the tangible impact of the Choosing Wisely campaign".

However, Robert Goldbert, for The American Spectator, criticized the program saying that it was "designed to sustain the rationale and ideology that shaped Obamacare" (the Patient Protection and Affordable Care Act), that the lists were "redundant and highly subjective", and that participants in the effort would greedily benefit at the expense of others if the campaign succeeded. A related critique is that considering cost as a basis for making health care decisions is not ideal.

While expressing the need for evidence-based healthcare recommendations, The Economist found the Choosing Wisely recommendations to be weak because they are not enforceable. In an editorial published in the Southwest Journal of Pulmonary and Critical Care, Richard Robbin and Allen Thomas express concern that the campaign could be used by payers to limit options for doctors and patients. However, they declare the Choosing Wisely recommendations a "welcome start."

Critics in the Southwest Journal of Pulmonary & Critical Care said, "the present Choosing Wisely campaign has fundamental flaws—not because it is medically wrong but because it attempts to replace choice and good judgment with a rigid set of rules that undoubtedly will have many exceptions. Based on what we have seen so far, we suspect that Choosing Wisely is much more about saving money than improving patient care. We also predict it will be used by the unknowing or unscrupulous to further interfere with the doctor-patient relationship."

Impact

The Choosing Wisely campaign makes no provision to scientifically research its own efficacy, but academic centers are making plans to independently report on the impact of the campaign. The campaign has been cited as being part of a broader movement including many comparable campaigns. The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system. In April 2014, Choosing Wisely Canada launched. Choosing Wisely Canada is organized by the Canadian Medical Association and the University of Toronto, and is chaired by Dr. Wendy Levinson. The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients' care and costs.

By 2015 and following the Choosing Wisely precedent established in the United States, health leaders from Australia, Canada, Denmark, England, Germany, Italy, Japan, the Netherlands, New Zealand, Switzerland, and Wales committed to bring ideas from the Choosing Wisely and sometimes even the actual campaign itself into their own countries.

ABIM Foundation

Choosing Wisely is an initiative of the ABIM Foundation, a not-for-profit foundation established by the American Board of Internal Medicine (ABIM) in 1999 to advance medical professionalism to improve health care. In 2002 the ABIM Foundation, along with the ACP Foundation and European Federation of Internal Medicine published Medical Professionalism in the New Millennium: A Physician Charter. Dr. Hal Sox, Editor of Annals of Internal Medicine remarked, “I hope that we will look back upon its publication as a watershed event in medicine.”

The Physician Charter sets forth a series of professional principles and responsibilities that physician should seek to embody in their practice, including the principles of the primacy of patient welfare, patient autonomy, and social justice. The Physician Charter has been endorsed by more than 130 organizations, translated in to 12 languages, and 100,000 copies have been distributed. In 2014 the ABIM Foundation partnered with McGraw-Hill to publish Understanding Medical Professionalism. The book was authored by medical professionalism experts Wendy S. Levinson, MD; Shiphra Ginsburg, MD; Frederic W. Hafferty, PhD; and Catherine R. Lucey, MD.

In 2011 the ABIM Foundation created the Professionalism Article Prize. The award “recognizes outstanding contributions to the field of medical professionalism” and is given to up to three winners annually. Previous winners have included articles published in Academic Medicine, the Joint Commission Journal on Quality and Patient Safety and the New England Journal of Medicine.

On 10th March 2015, an article written by Kurt Eichwald for Newsweek raised skepticism of the ABIM Foundation and its merit. ABIM Board Chair David Johnson, responded with a statement stating “The author also presents an untrue and misleading interpretation of information from ABIM and ABIM Foundation's tax returns. His reporting reflects a poor understanding of that information and a highly selective presentation of information designed to prove his faulty premises.” David also responded to the assertion that ABIM has a monopoly on certifying internists and other accusations.

Other Partners

Nine specialty societies agreed to participate at the project's start. These include the following:

• American Academy of Allergy, Asthma, and Immunology
• American Academy of Family Physicians
• American College of Physicians
• American College of Cardiology
• American College of Radiology
• American Gastroenterological Association
• American Society of Nephrology
• American Society of Nuclear Cardiology
• American Society of Clinical Oncology

Societies that began to participate starting in February 2013 include the following:

• American Academy of Hospice and Palliative Medicine
• American Academy of Neurology
• American Academy of Ophthalmology
• American Academy of Otolaryngology - Head and Neck Surgery
• American Academy of Pediatrics
• American College of Obstetricians and Gynecologists
• American College of Rheumatology
• American Geriatrics Society
• American Society for Clinical Pathology
• American Society of Echocardiography
• American Urological Association
• Society of Cardiovascular Computed Tomography
• Society of Hospital Medicine
• Society of Nuclear Medicine and Molecular Imaging
• Society of Thoracic Surgeons
• Society for Vascular Medicine

Societies beginning their participation between September 2013 and March 2015 include the following:

• American Academy of Dermatology
• American Academy of Orthopaedic Surgeons

American Association of Neuromuscular & Electrodiagnostic Medicine

• American College of Chest Physicians
• American College of Surgeons
• Commission on Cancer
• American Headache Society
• AMDA – Dedicated to Long Term Care Medicine
• American Society of Hematology
• ASTRO (American Society for Radiation Oncology)
• American Thoracic Society
• Heart Rhythm Society
• North American Spine Society
• Society of General Internal Medicine
• American Psychiatric Association
• American College of Medical Toxicology
• American Academy of Clinical Toxicology
• American Association for Pediatric Ophthalmology and Strabismus
• American Society of Anesthesiologists
• American College of Emergency Physicians
• The Endocrine Society
• American Society of Clinical Oncology
• Society of Gynecologic Oncology
• American Association of Critical-Care Nurses
• Society of Critical Care Medicine
• Society for Cardiovascular Magnetic Resonance
• Society for Maternal-Fetal Medicine
• American College of Occupational and Environmental Medicine

Societies which have expressed intent to participate in Choosing Wisely in the future include the following:

• American Academy of Physical Medicine and Rehabilitation
• AABB
• American Association of Neurological Surgeons
• American Association for the Study of Liver Diseases
• American Society of Colon and Rectal Surgeons

Consumer Reports creates and distributes versions of the information written in plain English. Communication partners to the public include the following:

• AARP
• Alliance Health Networks
• Leapfrog Group
• Midwest Business Group on Health
• Minnesota Health Action Group
• National Business Coalition on Health
• National Business Group on Health
• National Center for Farmworker Health
• National Hospice and Palliative Care Organization
• National Partnership for Women and Families
• Pacific Business Group on Health
• Service Employees International Union
• Wikipedia
• Union Plus

Further reading

• for an example of local public journalism of the campaign, consider

External links

• Official website
• Dr. Daniel Wolfson's posts on ABIM Foundation's blog Since March 2012, This person has posted commentary about Choosing Wisely
• Living well with breast cancer by choosing wisely: A conversation with Amy Berman, personal testimony from a geriatric care expert