A primary care doctor takes issue with Choosing Wisely

“You see, Dr. Oz was right, you’re ordering way too many tests for me,” a patient told me today after seeing news reports of today’s press conference in Washington DC by the Choosing Wisely campaign. This campaign, according to news reports (WSJPBSABCNBCNPR, AAFP, and others), points the finger directly at doctors for ordering “worthless” and unnecessary tests (that’s why the press, like patient advocates, love this story, because another opportunity to blame doctors). While I believe this is a noble cause, here are some of the issues that I have with it.

Where’s the patient responsibility? So, if I get this right, there is also going to be educational campaigns directed toward patients with slogans like, “Don’t expect that routine antibiotic for that cold,” or “Don’t expect routine testing if you’re asymtomatic.” There have been announced partnerships with consumer organizations like Consumer Reports Health, AARP, SEIU, and Wikipedia. Do you really think these groups will discourage patients from demanding unnecessary testing/treatments? Time will tell…

Thanks for making my job more difficult. With these reports today, patients are challenging me even harder about the testing and treatments that I am recommending. I don’t have a problem with this. However, I do have a problem how this story has been framed in that “I” am the reason why unnecessary tests are done, and my patients are more than happy to remind me of that.

Insurance companies must love this. Sometimes I really wonder if all these physician organizations really know how medicine is practiced at the grassroots by physicians like me. Every day, our office have staff members sit “on hold” for hours at at time trying to walk through the maze of preauthorizations for tests and medications. I really think this announcement will further embolden insurance companies (including Medicare/Medicaid) to raise the bar and make testing and treatment more difficult for me to adequately treat my patients.

Where’s the tort reform? Does anyone see that pink elephant in the room? Every time unnecessary tests are mentioned, physicians usually respond by saying things like “defensive medicine” and “fear of malpractice.” There have been many studies, arguably conflcting, asking the question about whether today’s medicolegal climate causes physicians to order tests that they maybe shouldn’t. I was disappointed that all these physician organizations had nothing to say about malpractice attorneys and the need for liabiility (meaning malpractice or tort) reform in this country. Everyone knows that it’s needed, but physician organizations are taking (in my opinion) the easy way out in blaming themselves and trying self reform first.

Here’s the dirty little secret. I’m a amateur pundit, but here’s what I think is really going on. All these physician organizations are afraid of the government (whether it’s Obamacare or other plan) ultimately deciding what tests should be done or not done. Private insurance companies are somewhat doing this now. So, if physicians can show that we can “police” ourselves, physician groups are hoping to score political points with those in Washington (that’s why the press conference was in DC today).

Now, don’t get me wrong. I agree with everything that happened today. 30 billion dollars annually of unnecessary tests are a real problem. However, will this effort really change the behavior of physicians? Probably not. Will this effort really try to educate patients not to ask for unnecessary tests? Probably not. Will this campaign hope to score political points with Congress and the White House? Some believe yes …

Mike Sevilla is a family physician who blogs at Family Medicine Rocks

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  • http://twitter.com/drmikesevilla Mike Sevilla, MD

    Thanks so much for posting the essay here. I very much appreciate it!

  • carolynthomas

    “..Will this effort really change the behavior of physicians? Probably not….”    Well, not likely if they believe as you do, Dr. S.

    As for patients changing their expectations about unnecessary testing, you’ll be delighted to know that Consumer Reports Health has already been helping to educate patients why they ought not to demand things like antibiotics for their sore throats.  And CRH’s pro-Choosing Wisely piece last week was a stellar example of being pro-active, not defensive:  http://www.consumerreports.org/cro/2012/04/choosing-wisely-how-to-avoid-unnecessary-tests-and-treatments/index.htm

  • http://twitter.com/drmikesevilla Mike Sevilla, MD

    Hello carolynthomas: Thanks so much for the link and for your comment. Just this morning, I was also sent a link about educating patients on appropriate use of antibiotics: http://www.aware.md/

    As I stated above, “I agree with everything that happened today.” It’s just that I’ve seen many campaigns like this in the past, but mainly directed at physicians/providers. Hopefully, with a concerned effort with patient advocacy groups and consumer groups, the tide can be turned and we can get the behavior change that we’re looking for…

  • southerndoc1

    “Sometimes I really wonder if all these physician organizations really know how medicine is practiced at the grassroots by physicians like me”

    You can stop wondering. They are totally clueless.

  • http://www.facebook.com/profile.php?id=100000652119019 Dave Comstock

    http://www.mskcc.org/cancer-care/patient/bruce“It was a regular check-up. A routine blood test. I felt no symptoms. In the 38 years since I broke my left femur as a boy, nothing medically interesting had ever happened to me. The next day my doctor called. I had an elevated level of alkaline phosphatase.”

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Great article. This entire thing looks like a good thing, but I couldn’t escape the fact that all materials have a disclaimer on the bottom relieving the advice givers from legal responsibility for the advice they give.
    So is this good advice (new standard of care?), or just a restatement of of the obvious that nobody wants to take responsibility for?

  • sFord48

    With the push toward market base healthcare and the complaint of doctors on this blog about patients getting too much care with no skin in the game, I thought we patients were supposed to question our doctors and make good financial decision based on our own research.  I am not sure why the author is complaining.

  • http://twitter.com/drmikesevilla Mike Sevilla, MD

    @southerndoc1:disqus Thanks for your comment. Witty as always@facebook-100000652119019:disqus I understand what you’re saying. There are always going to be stories like that. But continuing many (if not all) testing like this is just unsustainable.

    @MargalitGurArie:disqus Disclaimers like that are pretty standard. All treatment decisions should be between a physician and patient, and not by a news report or press conference

    @sFord48:disqus Of course patients should question doctors after making their own research. But, what if I question a patient about NOT getting a test or NOT giving antibiotics? Does this make me a bad doctor? Some say yes. And, some may go to the ER (more expensive care) or urgent care and get what they want anyway. That’s why I applaud the patient education steps that are being taken by consumer groups and patient advocates. I know that tort/liability reform is a huge task. But, with this, ER (and other specialty) docs can also have the medicolegal courage to say no as well to testing they feel is unnecessary…

    • sFord48

      Doctors (or other qualified providers) order all unnecessary tests.  They do so because they are unwilling to say no to a patient, they are worried about themselves (getting sued), or they will make a profit.  While I have never insisted on a medical test, I did have a doctor that wanted to cut half my breast off to be sure he didn’t get sued and another who wanted to do an MRI on the only machine in the area with the high enough quality that he just happened to own.  

      When confronted with a doctor’s recommendation, I have to decide whether to follow my doctors advice.  The Choose Wisely seems like a step in the right direction. 

  • http://www.facebook.com/people/Molly-Cooke/567191747 Molly Cooke

    Full disclosure, I am active in the American College of Physicians, a participant in the Choosing Wisely campaign.  I am also a practicing general internist with a mixed panel of patients with the typical complex chronic illnesses we see in IM and HIV.  I spend far more time explaining to patients why they don’t need interventions, diagnostic and therapeutic, that they think they need than trying to persuade the wary ones.  If the work of the Consumers Union in partnership with Choosing Wisely decreases the number of conversations that I have in the first category by 25%, I’ll have plenty of time to spend a little more time explaining to a cautious patient why I am proposing a particular test or treatment.  Frankly, I don’t mind doing this.  It is always better if the patient has a clear understanding of the rationale for an intervention than if he just does it because I suggested it.  

  • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

    the reason I don’t agree with you is that it is easy to explain the extra test or so…….”I know routine EKGs are not generally recommended for XYZ, but the reason I think it is important in your specific case is ABC…..”    Then, you have made a patient specific judgment, which is what docs were trained to do, and explained it to the patient to get their buy-in and consent to spend more $$$$ ( informed consent isthat troublesome term that we frequently forget unless we are going to do something with some risk, but it pertains to expenditures as well)

    The time spent on this will be dwarfed by the time saved when the public realizes that they do not need antibiotics for colds, etc.   Publicity about too many tests will eventually also resonate with juries and plaintiff’s attorneys evaluating cases (if there are clear guidelines about not ordering imaging for back pain unless red flags are present, it’s pretty clear that cases will not be brought on that matter unless something is really unusual)

  • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

    sorry….pertains to expenditures or financial risk as well.   

  • Marc Frager

    I don’t trust anything from ABIM. They need to follow their own recommendations and cut the cost of their widely criticized MOC program. The head of the ABIM has a salary of about 4 times the average internist salary which is coming from their MOC program. They have repeatedly commented that they are aware of the critcisms, but have adamantly refused to change anything.  They have not yet produced the data that their test is even effective after at least 37 years of recertification. When they do what they tell others to do, they are then worthy of credence.

  • Margaret Polaneczky

    Mike- 

    I believe the biggest obstacle to lowering healthcare costs is the fear of malpractice that drives so much of our unnecessary testing. We must get tort reform that protects docs against lawsuits for failure to diagnose.

    Great post!

    Peggy 

  • CanadianDoc

    Very interesting – the concept of Physician-Induced-Demand in a private health care system has been widely argued for some time. One of the main issues is the information imbalance between patients and doctors; does the general public possess enough medical knowledge to judge what is medically necessary?

    You might be surprised that the issue of “over investigating” and utilization of healthcare resources is just as rampant North of the border, in a publicly-funded system… Check out the some discussions around healthcare economics in this Canadian blog:

    http://frontdoor2healthcare.wordpress.com/2012/03/20/what-is-a-physician-worth/

  • http://www.facebook.com/people/Alieta-Malwitz-Eck/565880983 Alieta Malwitz Eck

    Real common sense health care reform will come when physicians get back to providing care to patients who pay for their own services. When no third party is involved, excess testing is eliminated. What patient would agree to paying for an expensive test unless his physician could explain how it will help guide his care?

    Medical inflation began in 1965 when the government got involved and people developed the mentality that there is a giant pot of money ready to be accessed. Lawyers entered the fray to cash in as well, as this is when our medical malpractice system exploded.

    Medical insurance should be “major medical,” paying only for the costly unforeseen medical events, never the routine.

    Patients, physicians and taxpayers will do well once we get the government out of medical care. ObamaCare must go and common sense must return.

     

  • Doc ForthePeople

    “Choosing Wisely” is made up of the “Big Boys” …. so where is the voice of the common person in all this? It isn’t! And what of the diseases that are yet to be understood….there is no “evidence” yet on those. The “Choosing Wisely” movement seems to me to consist of maintaining vested interest in the established tests and rewards for those specialists served by those special interest groups (for the uninitiated, SIGs at medical meetings are groups of docs who are devoted to a specific special interest). Buyer beware…

  • http://profile.yahoo.com/RP7QBRAYN2HWC5STGR7TCHQHWY paul

    So let’s talk about the needless testing of doctors by the ABMS and their affiliates. NO proof of value to MOC at any level (except that test takers show better results at taking tests-never real life validity)! Talk about WASTED MONEY FOR NEEDLESS TESTS! An C Cassel, MD, head of ABIM gets to talk on the evening news against necessary testing by doctors in a vacuum!

  • http://www.zdoggmd.com ZDoggMD

    GREAT post Mike, spot on! Especially the Dr. Oz reference. I LOVE that guy: http://zdoggmd.com/2011/06/sucker-mds/

  • Maura69

    I am extremely lucky to have a doctor that does not prescribe to unnecessary testing procedures. I am a stage IV Cancer survivor with a very convoluted medical history with more than 30 major surgeries, 3 being life threatening. Due to the disability compromised by the cancer I am in severe, inoperable pain, consequently my Dr. and I work together for adequate pain relief accompanied with physical therapy. I am never out of pain, there is only degrees of comfort. There have been major problems with Insurance Companies as well as the DEA. For the most part the Insurance wanted more testing and the DEA wanted to try different drugs first, (although repeatedly they (DEA) were informed of severe allergies). With my Dr.’s staunch support I am doing fairly well and now am able to walk around to block – albeit slowly, but able. We do not need Politics/Government interference in the medical field, we need more Doctors to stand up and fight for their patients and for the right to be the Doctor that they went to school for. 

  • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

    Patients need to be responsible too. Many tests are patient driven – and not just in the USA. Still education programs like this are a good start