Brandon Maughan, MD, recently published data from a survey of emergency department chairs and division chiefs at institutions with allopathic emergency medicine training programs. Of the 134 programs invited, 78 percent participated in the survey. Of those, 84 percent had heard of the Choosing Wisely campaign, while only 45 percent of the academic chairs had discussed this directly with patients, and approximately 50 percent could recall any of the ACEP recommendations.4
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ACEP Now: Vol 35 – No 02 – February 2016Put Choosing Wisely Into Practice
It’s time to make this campaign relevant by taking it to the bedside, benefiting both patients and providers. Avoiding unnecessary tests and treatments makes the emergency physician’s job easier while providing value-added service for the patient. However, patients may not recognize that “less is more” without education. To that end, shared decision making is an excellent tool that empowers the physician, through bedside education, to align patients’ desires for quality care with the payers’ interest in reducing cost and physicians’ interest in efficiency, achieving everyone’s goal for cost-effective care.
Many physicians struggle with how to introduce these recommendations into clinical practice. However, ACEP and the ABIM Foundation have developed resources to assist. ACEP has committed to translating the ideas of Choosing Wisely into action on several fronts. The recently launched ACEP Clinical Emergency Department Registry includes the development of five quality measures that enable emergency clinicians to report on the quality of imaging decisions to the Centers for Medicare and Medicaid Services for the Physician Quality Reporting System program. ACEP was recently awarded a Transforming Clinical Practice Initiative grant from the Centers for Medicare and Medicaid Innovation to launch a national learning collaborative supporting emergency departments and individual clinicians in implementing these Choosing Wisely recommendations. Under this grant, ACEP will also be offering new eCME modules and partnering with the American Board of Emergency Medicine to integrate more Choosing Wisely topics into the Lifelong Learning and Self-Assessment and Maintenance of Certification practice improvement activities list
Below are several steps that may be useful to incorporate Choosing Wisely into your practice. Let’s take ACEP’s Choosing Wisely recommendation #9 (below), prescribing antibiotics for uncomplicated sinusitis, for example. (It is available online at www.choosingwisely.org/clinician-lists/acep-antibiotics-in-the-ed-for-sinusitis.) Many patients expect to receive antibiotics for “sinusitis.” We have to educate them about their lack of efficacy and give them a reason to not want antibiotics.
Step 1: Plant the seed of your recommendation: “You know, you may not need antibiotics, and they could be harmful to you.”
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5 Responses to “Emergency Physicians Should Put Choosing Wisely Recommendations Into Action”
March 13, 2016
AliseWithout tort reform choosing wisely are just empty words. Nobody is rewarded for ordering less. Start from the beginning..if choosing wisely was accompanied by incentives that didn’t conflict with the rewards of the current system perhaps it would be more successful.
March 13, 2016
William Fisher, MDYou guys just don’t get it. Choosing wisely is a euphemism for saying “help decrease the cost of medical care and be liable for any of your mistakes.” Without tort reform that gives me complete protection if I follow choosing wisely and safe harbor guidelines, I do not intend to modify my practice in any way. I’ll say it again, I will not participate in any program that increases my medical liability. When legislation is passed that says I cannot be sued if I follow choosing wisely or Safe Harbor guidelines, I will be happy to modify my practice.
March 13, 2016
Jerry W. Jones, MD FACEPIn order to implement these recommendations, every physician or healthcare provider must feel assured that he/she isn’t missing a red flag or overlooking a finding that would indeed indicate the utilization of one of these tests. However, in order to achieve this degree of assurance, one must perform a good history and physical examination. That doesn’t happen nowadays.
The “history” consists of a few perfunctory questions asked from a computer template that often has little association with the top two or three conditions in the patient’s differential diagnosis. It is typically acquired without the physician ever looking at the patient and without giving the patient an opportunity to interject a comment.
The physical exam – if done at all – consists of a “stethoscope tap” in which the diaphragm of the scope is placed on the right and left upper chest for less than one second in each location – and the “belly pat,” in which one hand is placed on the patient’s abdomen – usually with the patient fully-clothed, without even indenting the contour of the abdomen. In fact, you can find more and more physicians who pride themselves on NOT doing a physical examination, claiming that a physical exam is a dinosaur and no longer pertinent in a digital, technologically-advanced world. I recently attended a symposium in which a number of speakers actually mocked physicians who still do physical exams.
Thus, the only way left nowadays for many physicians to feel “assured” that they are not missing a “red flag” is to order an abundance of unnecessary tests that would have been obviated by a decent history and physical examination.
March 13, 2016
Freda Lozanoff DO FACEPThe patients who come to the ER want tests, not a dissertation on why they are not necessary. This is the mind set. Every survey has shown that more tests, even negative, generate better evaluations and insure your job.
March 13, 2016
joelDr Klauer
I enjoyed reading your article and agree!
For me, the challenge remains how to we not give a patient what he/she wants (regardless of need!) and still obtain 5/5 on our patient satisfaction scores?
Patients expect antibiotics for everything and new exciting scans and tests even if the onset of the symptoms is exactly 5 minutes longer than their door to provider time. We expect them to pay a ridiculous copay in credit card or cash at the time they are seen. (My employer’s plan has a $250 copay for every ED visit.) Then we “refuse” to give them what they want and we expect them to be happy for it and give us positive reviews? I have worked in several large EM groups and have heard numerous clinicians state they have dramatically increased their patient satisfaction scores by 1. ordering every scan patients want and 2. giving patients any prescription they want regardless of indication, medical necessity or need.
For many years providers were able to tell patients “this is not in your best interest and can even be detrimental to your health” “studies have shown . . . . ” when discussing tests, treatments, scans and prescriptions. “No ma’am your child does not need a CT scan of his head after being shot in the head with a Nerf gun from across the room his risk of cancer from the scan FAR outweighs any potential benefit.” You can explain and produce research until the cows come home, but mom is in the ED to get a CT scan and sending her home without it leads to an unsatisfied patient experience, resulting in patient complaints, poor satisfaction scores and directly effects both your income and the income of your employing institution.
My family went out to eat last night. If the server had refused to serve the food I ordered because I am expanding at the waist line and hundreds of studies and years of research had shown this particular dish to be detrimental to my health, I likely would have refused to pay the bill, skipped the tip and posted something unflattering on a web site reviewing that establishment. Lets be honest most patients are not in the ED to hear about what is best for them or what a study shows, patients are in the ED to get what they want. And if they don’t they will be unsatisfied with their visit, period. If IV Vancomycin “cured my sniffles in 30 seconds flat last time I was here,” then they expect IV Vancomycin at every visit for those complaints.
Until this issue is resolved providers will read articles like this nod their heads in agreement and then sadly ignore these recommendations in favor of income and employment security.
Respectfully yours,
Joel