Choosing Wisely is the health reform we need

Let me tell you about a possible paradigm-changing idea in the seemingly hopeless matter of controlling runaway healthcare costs—a topic that has far-reaching implications, not just for healthcare, but for our nation’s economy and vitality.

Organizations of doctors have decided to embrace common sense in the practice of Medicine.

Led by the American Board of Internal Medicine Foundation and joined by many other medical societies, the Choosing Wisely movement aims to promote care that is:

  • Supported by evidence
  • Not duplicative
  • Free from harm
  • Truly necessary

Nine medical groups—with more coming on board soon—were asked to compile a list of 5 misused or overused tests. The American College of Cardiology listed these ground-breakers:

  • Cardiac imaging should not be performed routinely in patients without symptoms or high-risk.
  • Cardiac imaging should not be performed for routine follow-up in patients without changes in symptoms or signs.
  • Cardiac imaging should not be performed prior to low-risk surgery.
  • Echocardiograms should not be done to follow-up non-symptomatic patients with mild valve abnormalities.
  • Patients with heart attack treated with emergency stenting should have stents placed only in the culprit vessel.

These are not misprints. The leaders of American cardiology have gone on the record against nonsensical and wasteful — but some say “thorough” testing. Wow!

As a minimalist and (budding) master-of-the-obvious clinician, these proclamations of common sense make my heart sing. But that’s not all. Choosing Wisely isn’t just about smarter cardiology recommendations. (Although, if implemented, these heart recommendations alone would greatly reduce unnecessary healthcare costs.) Other medical societies have weighed in with equally ‘epic’ suggestions:

  • Radiologists recommend performing fewer head imaging studies for headaches and fewer chest CTs in the initial evaluation of suspected lung blood clots (PE).
  • Family doctors urge doing fewer MRIs for low back pain and prescribing antibiotics less aggressively for uncomplicated sinusitis.
  • GI doctors call for less repeat colonoscopies after an initial negative test, fewer CT scans of the abdomen and titration to the lowest dose of medicine to treat reflux.
  • Internists repeat the call for fewer MRI scans of the low back, avoiding head-imaging tests for simple faints, and echo the ACC recommendations to not do routine stress tests in low-risk patients.

This stuff is huge. We all know healthcare costs are spiraling out of control. Most agree that the reforms argued in front of the Supreme Court recently don’t address the issue of controlling costs. Government regulation tries to limit costs by covertly (or overtly) inserting itself in the doctor-patient relationship.

Effective healthcare reform will not come from the government.

Doctors must design and implement healthcare changes and reforms. Call us what you will, but we are the experts in medical diagnosis and treatments. We know what works and what doesn’t. We must be allowed to practice Medicine–not just follow protocols, or test and treat just to cover our butts. The corollary here, of course, is that we must be allowed to be human. What my favorite cyclist, Fabian Cancellara, says about cyclists holds true for doctors too: “We are not cyborgs, only men.”

That our thought leaders are now proclaiming–and social media is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.

Writing about this feels so good. Not just because my approach to the practice of medicine has come back in vogue, but because I care so much about the human aspects of our profession. Because it matters so.

John Mandrola is a cardiologist who blogs at Dr John M.

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