The top-five lists, as they are called, are designed to encourage conversations between physicians and patients about low-value medical care. Physicians are increasingly ready to have those conversations, says Mitchell Schwartz, MD, chief medical officer & president, Anne Arundel Medical Center. “The way to thrive is to save money that is being wasted and that doesn’t add value to the patient,” he says.
Choosing Wisely has its roots in a project initiated by the National Physicians Alliance. Stephen Smith, MD, a family physician who came up with the idea, worked with three primary care specialties on the first top-five lists. The publication of those lists created such a splash that the idea quickly spread.
Lowell Schnipper, MD, an oncologist at Beth Israel Deaconess Medical Center, says physicians know that emerging payment systems will require them to practice high-value care, and the top-five lists help them do just that. “I think this is the vanguard of what is going to be a sea change in the way physicians practice,” he says.
What feedback are you getting from physicians and others as they learn about the Choosing Wisely campaign and the top-five lists?
Schnipper: I chair the American Society of Clinical Oncology’s Cost of Cancer Care Task Force, which developed that society’s top-five list. Initially, patient advocacy groups asked me some very pointed questions about several of the items on our top-five list. Cancer is terrifying to patients, and the advocates were worried that we might be abrogating patients’ very last possible chance for a cure. So it took some explanation, but I think the patient advocacy groups now have a clear understanding of the goals of trying to provide intelligent care that is evidence-based. Ultimately, care rooted in high-quality evidence will provide our patients with the best and safest care available.
As for oncologists, they have come up to me at committee meetings and events and congratulated us on the top-five list. They say that it has helped them immensely in their office practices because the five items that we selected for the list have been shown in the medical literature to be unnecessary. I think the oncologists feel that providing authoritative support like this helps them to communicate with patients about something that is otherwise very challenging from an emotional and factual level.
The positive reaction has been sufficient to stimulate us to pick another five tests and treatments, which will make it a top-10 list. That work will begin next year.
What are the barriers to physicians making high-value medical care decisions?
Schwartz: When a patient comes to the emergency department with a headache and expects to get an MRI, it’s very challenging to say “No,” even though we understand that the tests may be superfluous. There is a cultural expectation that, “I’m here for a test and a prescription.”
We feel that, slowly but surely, with patient education and exposure—such as is happening with the Choosing Wisely campaign—this cultural expectation will be modified.
Smith: The Choosing Wisely approach is financially disadvantageous to physicians. A woman I know told me that she had an EKG every year as part of her annual exam even though she is a low-risk patient. So when she said, “No, I don’t want an EKG,” her internist said to her, “I agree with you that we really don’t need to do this, but because there are so many things that we’re losing money on, my practice has decided that this is something we can make money on.”
I think most doctors want to do the right thing, and the Choosing Wisely campaign gives them the authoritative support for doing that.
The most powerful barrier is the acculturation of doctors. We train our medical students and residents to abhor uncertainty and to leave no stone unturned. When I was in medical training, we would go on rounds, and the attending physicians would start asking questions: “Did you do this? Did you get that test?” The attendings would always find a test that was not ordered, and then they would humiliate the offender. And we would say to ourselves, “I’m never going to let that happen again. I’m going to make sure I order every possible test.”
It’s a whole new way of thinking for physicians to raise the issue of whether we are going to exhaust our resources, financial and otherwise, by wasting money on things that are very, very low probability—and may actually be harmful to patients. I think we’re at a tipping point right now in terms of culture changes, but this really is a culture war.
How can hospital executives engage physicians to consider resource use?
Schwartz: Having a meeting where resource utilization is discussed can occur only after a long effort of education and trust building. If that education and trust building has not happened, then the typical response to this discussion is a hunkering down of, “I know what I need to do for my patients, and you’re just interested in money.”
On the other hand, if there is true physician leadership and the pronoun “we” is used frequently—in terms of everybody is responsible for patient care—then you can really have a good discussion about this. As long as hospital leaders put the patient’s welfare at the top of their priority list, doctors are more than willing to have a lot of discussions regarding the cost-effectiveness of care. Having a group of doctors sit around a table and discuss the nuances of best care and best practices is typically a very engaging dialog that easily works itself out into a set of guidelines.
Once you get to that discussion point with doctors, they get to define the best practices. Executives should elevate the physicians into leadership roles to make those decisions.
What can hospital executives do to encourage physicians to adopt the Choosing Wisely top-five lists for their specialties?
Schnipper: They can use their electronic health records to monitor whether physicians are complying with best practices. There’s nothing that doctors respond to better than being shown data that they are responsible for.
In addition, hospital administrators should encourage educational programming that is focused on the quality of care through evidence-based medicine. Where appropriate, physicians should be encouraged to develop care pathways that define the proper evaluation and therapeutic interventions for specific clinical problems. Studies in clinical oncology have demonstrated that patients can be optimally treated for, as an example, advanced non-small cell lung cancer by adhering to pre-defined clinical pathways for that particular problem—while reducing expenses by 35 percent.
Smith: First of all, publicly endorse the top-five lists and the Choosing Wisely campaign.
Number two: Tout the Choosing Wisely approach to all hospital employees. Tell them, “When you go get your physical this year, if you don’t have any risk factors, you should not be getting an EKG and you should not be getting a lot of chemistry tests—that’s not good medical care.”
We have to make sure that people understand that this is the right medicine. This is not rationing—and patients are actually putting themselves at risk for medical misadventures by doing things that are not indicated by evidence. The hospital CEO ought to be up there in front, saying “When I get my physical, I want only the things that are right for me, and I don’t want all these unnecessary and wasteful practices.”
Also, hospitals can sponsor grand rounds to educate physicians about the Choosing Wisely campaign. There are a lot of us who know about this, so get a local physician to give a talk and slide show.
What I would not do is set insurance benefit designs around the top-five lists. We are really trying to focus this in terms of a professional conversation between doctors and patients—and not have payers come in prematurely and say, “We’re not going to pay for this.” I think there would be a risk of a backlash if there was aggressive benefit design based on these recommendations.
How do you coach physicians to have conversations with patients that lead to high-value decision making?
Schwartz: We do not get into the “this is how much it’s going to cost” discussion. In the emergency department, we basically take a patient’s full history, conduct the appropriate testing, and review the results with the patient. We say to the patient, “At this point, there’s no indication of risk, and we feel comfortable sending you home. You can always be reevaluated over time by your physician, and we don’t think at this juncture an MRI is required.”
In a busy emergency department, when you as a physician walk into the room, the patients don’t know you or what your experience is. It is your job—in three minutes—to introduce yourself, gain their respect, and help them understand that you are there to help them. If you can do that, you can have an enlightened discussion. There are ways to help the patient make the right decision through a two-way discussion, as opposed to saying, “Look, I’m the doctor, do what I tell you.”
The National Physician Alliance has a top-five demonstration project in three primary care practices under way. Any lessons learned so far?
Smith: The lesson learned is that it is easy to comply with the top-five lists for primary care and that one shouldn’t have great trepidation about adopting them. Many of our field testers were concerned that they were going to get a lot of push back from patients, but it just doesn’t happen. Patients trust their doctors. Physicians should approach these conversations knowing this is the right thing to do, and communicate that they are always open for a conversation because patients may have unique circumstances that need to be considered. It is rewarding to know that you’re doing the right thing—so have the courage to do it.
The other thing we have learned is that five is a good number as opposed to 15 or 50. This is a very manageable list, and providers can easily keep them in mind. Our hope is that, by practicing this way, we are going to begin to change the hearts and minds of the doctors so they start thinking of themselves as good stewards who always ask the question, “Why am I doing this? Is it the right thing? Am I being mindful of the costs of care and the harms and risks of care?”
That doesn’t mean not doing what the patient needs. But there is no ethical obligation to do things that are wasteful or actually harmful to the patient.
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