Step 2: Develop your 30-second monologue explaining Choosing Wisely. For example: “The campaign is designed to provide only valuable treatments for patients based on the current evidence from research. This also helps to avoid injury to patients from treatments they don’t need.”
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ACEP Now: Vol 35 – No 02 – February 2016Step 3: Select one of the seven supporting citations accompanying #9 to support your treatment recommendation. For example: Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;2:CD000243.
Step 4: Take one or two quotes from the article that suggest a lack of efficacy. For example, “There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80 percent of participants treated without antibiotics improved within two weeks.”
Step 5: Select one or two additional reasons the treatment may be harmful. For example:
- Antibiotic resistance is an issue. http://www.cdc.gov/drugresistance/
- Altering one’s individual microbiome may be harmful.
- Ursell LK, Metcalf JL, Parfrey LW, et al. Defining the human microbiome. Nutr Rev. 2012;70(Suppl 1):S38-S44.
Step 6: The safety zone: make a statement open to antibiotic use in the future but confirming you won’t be prescribing any today. For example: “Today it looks like you have a virus, which won’t respond to antibiotics. If you don’t get better, we can always use antibiotics at a later time, when it might be possible that you have a bacterial infection.”
Step 7: Confirm the patient is on board with the plan and document that in your medical record. If they’re still not on board, you may consider writing them a “wait-and-see prescription” (not to be filled unless their symptoms don’t improve by a certain date).
With a little preparation, we can all help translate the recommendations from the Choosing Wisely campaign into practice improvements.
Dr. Klauer is the chief medical officer–emergency medicine and chief risk officer for TeamHealth as well as the executive director of the TeamHealth Patient Safety Organization. He is an assistant clinical professor at Michigan State University College of Osteopathic Medicine and medical editor-in-chief of ACEP Now.
References
- Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely campaign. Acad Med. 2014;89:990-995.
- Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175:1913-1920. Brownson RC, Kreuter MW, Arrington BA, et al.
- Brownson RC, Kreuter MW, Arrington BA, et al.Translating scientific discoveries into public health action: how can schools of public health move us forward? Public Health Rep. 2006;121(1):97-103
- Maughan BC, Baren JM, Shea JA, et al. Choosing Wisely in emergency medicine: a national survey of emergency medicine academic chairs and division chiefs. Acad Emerg Med. 2015;22:1506-1510.
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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