“Without tort reform, Choosing Wisely are just empty words. Nobody is rewarded for ordering less.”
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ACEP Now: Vol 35 – No 05 – May 2016No argument from me. If we are asked by government agencies to reduce cost at the expense of diagnostic accuracy, we should expect professional liability protection or indemnification for doing so. However, I see Choosing Wisely differently. First, this is not a mandate from a federal or state agency. This initiative was generated from the medical community. Second, the goal, as defined by the American Board of Internal Medicine Foundation, isn’t specifically to reduce cost. According to the foundation’s website, “[Choosing Wisely] calls upon leading medical specialty societies and other organizations to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed with patients.”
I’m not a champion for the Choosing Wisely campaign, but I do see value in its premise and the tools provided to guide us in meaningful discussions with our patients to avoid the use of low- to no-yield tests and procedures. I see more good than harm and even feel that incorporating these tools with shared decision making can be used to our advantage. Fewer tests equate to earlier dispositions and operational decompression of our EDs. Over-testing doesn’t improve diagnostic accuracy but increases cost and patient risk without added value. Choosing Wisely offers evidence-based recommendations, developed by emergency physicians for emergency physicians, which may serve as a basis for medical malpractice defense in the event that a bad outcome occurs from their adoption.
References
- Dowd BE, Kralewski JE, Kaissi AA, et al. Is patient satisfaction influenced by the intensity of medical resource use by their physicians? Am J Manag Care. 2009;15(5): e16-21.
- Froehlich GW, Welch HG. Meeting walk-in patients’ expectations for testing. effects on satisfaction. J Gen Intern Med. 1996;11:470-474.
- Mangione-Smith R, McGlynn EA, Elliott MN, et al. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800-806.
- Schwartz TM, Tai M, Babu KM, et al. Lack of association between Press Ganey emergency department patient satisfaction scores and emergency department administration of analgesic medications. Ann Emerg Med. 2014;64:469-481.
- Cook C. The lost art of the clinical examination: an overemphasis on clinical special tests. J Man Manip Ther. 2010;18(1):3-4.
- Johnson DA. Value of the lost art of a good history and physical exam. Clin Transl Gastroenterol. 2016;7:e136.
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2 Responses to “Opinion: Emergency Physicians Challenge Implementing Choosing Wisely Recommendations at Bedside”
June 19, 2016
Myles Riner, MDOne of the reasons that ACEP’s Choosing Wisely campaign has not been widely adopted is, in my opinion, a lack of useful and necessary materials and tools to assist ED physicians and staff in implementing these shared decision-making recommendations. As a member of the ACEP CW Delphi panel and Cost Effective Care Task Force, I tried to get the ACEP Board to extend the task of the TF to include the production of such a ‘tool kit’, and this suggestion went nowhere. I then proposed to organize the development of this toolkit as a for-profit enterprise, and license from ACEP the supporting materials that were developed by the TaskForce. This toolkit would have included: education materials for staff and patients; videos; scripts for providers; targets and metrics for monitoring; supporting handheld apps; templates for feedback forms, dashboards, disclosure notices and even shared savings incentive program guidelines. This proposal to the Board was also turned down, apparently because the rules prevent committee or task force members from using committee work product in this way. I wonder how many times these rules have discouraged participation in similar ACEP projects? Other specialty societies have developed similar materials to help their members adopt CW strategies, but ACEP was content to put out its list and a few one-pagers and leave it up to members and EP groups to find their own way. Such a toolkit might have helped EPs to overcome many of the objections and impediments mentioned in response to this article. Opportunity lost.
June 19, 2016
Mark J. Cotter, PA-CThanks for references debunking the belief that “giving patients what they want” is the key to improved patient satisfaction scores, but is what I instead see as a lazy way out of doing our job. As health care providers, we are charged not with “satisfying” our patients, but taking care of them. It certainly is easier to write for an unnecessary prescription or test than it is to explain the reasons they may not be in the patient’s best interest. Sure, some remain unconvinced, and sometimes I order/prescribe things that patients have much more faith in than I, but the vast majority of my patients express gratitude and relief that I am a caring provider, even if they don’t get what they initially were seeking. Thanks for advocating we do the right thing.