Editor’s Note: We received many responses to February’s article, “Time to Walk the Walk: Choosing Wisely and knowledge translation” by Dr. Klauer. Here are a few of the comments from the emergency medicine community.

I enjoyed reading your article and agree! For me, the challenge remains how do 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 five 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 wants 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 and 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 waistline 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 website reviewing that establishment. Let’s 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.

—Joel

In order to implement these recommendations, every physician or health care 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.

—Jerry W. Jones, MD, FACEP
Mequon, Wisconsin

The patients who come to the ER want tests, not a dissertation on why they are not necessary. This is the mindset. Every survey has shown that more tests, even negative, generate better evaluations and ensure your job.

—Freda Lozanoff, DO, FACEP
Furlong, Pennsylvania

You 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.

—William Fisher, MD
Seabrook, Texas

Without 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.
—Alise

Perhaps, I didn’t “choose wisely” when I chose to write an article about the Choosing Wisely campaign. After climbing out from underneath the pile and dusting myself off, I’m ready to address the great comments we received on this topic.

Important conversation is exactly what we need for the specialty to formulate a consolidated and unified voice on any given issue, including Choosing Wisely. ACEP made the decision to join this campaign for a variety of good reasons. However, participation is a long way from fully understanding the implications of such a program at the bedside. The ACEP leadership will rely on its members to help fully inform their perspectives on the experiences and concerns of emergency physicians with respect to Choosing Wisely.

Joel, thank you for the support. Although I think vancomycin is a pretty big gun for the common cold, I get your point. Patients often have unrealistic expectations that find their roots in assumption and mere coincidence as opposed to cause and effect; nonetheless, such expectations persist. Compounded with the pressure of performing to experience-of-care metrics, this somewhat creates the perfect storm. However, this is only true if you believe two things: 1) patient expectations cannot be changed, and 2) patients value the “test” over sound medical advice. Personally, I don’t believe either of these to be true. Although this perspective may not have much of an audience, it may be worth sharing. Changing preconceived notions about what care should be provided is all about education, and once effectively educated to the lack of utility of what they want, including any negative consequences, most reasonable patients will opt for appropriate care.

I take exception not with you but with the premise that ordering more tests, prescribing antibiotics, and—let’s add one more myth—prescribing more opioids result in better scores. Joel, you’re in good company. Freda also raised this important and common concern. I respect it but simply have a difference of opinion.

Dowd et al reported that increased utilization did not correlate with improved scores, while Froehlich and Welch noted that in patients who expected diagnostic testing, “provider humanism” was the sole significant predictor of patient satisfaction.^1,2 Regarding prescribing unnecessary antibiotics, Mangione-Smith et al found that good communication influenced parental satisfaction regardless of whether antibiotics were prescribed or even expected.³ Finally, Schwartz concluded, “However, in the multivariable analysis, receipt of analgesic medications or opioid analgesics was not associated with overall scores.”⁴ I expect some will challenge the quality of this evidence refuting that satisfaction is linked to tests, antibiotics, and opioids, but to them I ask, is there higher-quality evidence proving the hypothesis that they are linked?

In my opinion, two of the emergency physician’s greatest tools are bedside education and communication. When you know why they want a test, perhaps you can change expectations. Just telling people they don’t need a test isn’t education; it’s a demoralizing smackdown. Your question reminds me of a patient I saw a couple of years ago who had been experiencing a cough for a week. He was adamant about getting a chest X-ray. After explaining the lack of utility of a chest X-ray, he wasn’t the least bit dissuaded. I asked, “What concerns you about your cough? Why do you want an X-ray?” He replied, “My father had a cough, and when they finally did a chest X-ray, they diagnosed him with lung cancer.” This wasn’t about the test; it was about an uneducated fear of lung cancer.

In my opinion, two of the emergency physician’s greatest tools are bedside education and communication. When you know why they want a test, perhaps you can change expectations. Just telling people they don’t need a test isn’t education; it’s a demoralizing smackdown.

Despite attempts to educate them, some patients may not change their minds. However, even if you acquiesce to some of those demands, you still have reduced unnecessary testing for so many more. Choosing Wisely provides us with a tool. It is not only an evidence-based educational tool but an authority that supports your advice and to divert the heat toward.

Jerry, very interesting perspective, and I completely agree. The advances in and availability of medical technology have fallen victim to the law of unintended consequences. With overreliance on diagnostic technology, the art of physical examination has begun to erode.^5,6 Testing used to confirm the concerns developed through a thorough history and physical examination, but now, all too often, it’s the other way around; the physical examination takes a back seat to the diagnostics. The “right” tests complement a good history and physical examination, but more tests will never be a substitute for the art of bedside diagnosis.

Bill and Alise, I sense your frustration and suspect you speak for a great many who are simply sick and tired of well-intentioned bureaucrats who have developed a financial conscience, demanding fiscal responsibility and stewardship while asking physicians to do much, much more with far, far less. Your comments strike the most important points with laser-like precision.

“Help decrease the cost of medical care and be liable for any of your mistakes.”

“Without tort reform, Choosing Wisely are just empty words. Nobody is rewarded for ordering less.”

No 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

1. 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.
2. Froehlich GW, Welch HG. Meeting walk-in patients’ expectations for testing. effects on satisfaction. J Gen Intern Med. 1996;11:470-474.
3. 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.
4. 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.
5. Cook C. The lost art of the clinical examination: an overemphasis on clinical special tests. J Man Manip Ther. 2010;18(1):3-4.
6. Johnson DA. Value of the lost art of a good history and physical exam. Clin Transl Gastroenterol. 2016;7:e136.