ACP: 5 excuses physicians and patients should question

acp-logoA guest column by the American College of Physicians, exclusive to

Whether we call them “unnecessary,” “not indicated,” “inappropriate,” or “overused,” certain tests and procedures add little or no clinical benefit to patients and in some cases they cause harm. They also contribute to the cost of care without improving care. At a time when payers are challenging payment for legitimate services that patients need, the medical profession should lead the way in reducing the wasteful medical care over which they have control.

On February 21, Choosing Wisely, an initiative of the ABIM Foundation, announced the participation of 17 additional medical societies, each of which released a list of five commonly done tests or procedures whose use should be questioned by physicians and patients. ACP was one of the first groups to release a list in April 2012, and prior to that established its High Value Care initiative that shares the goals of Choosing Wisely. More societies will publish their own lists later this year.  I won’t describe the items here but suggest that you read them on the Choosing Wisely webpage.

In the spirit of the Choosing Wisely campaign, I would like to add my own list of five items. These items are not tests or procedures, but excuses that physicians and patients should question. They are reasons that some physicians raise for not following recommendations such as those in Choosing Wisely. I came across all of these following the recent ABIM Foundation announcement.

Here is my list of five commonly-used excuses for not implementing recommendations for high value care:

1. We can’t follow these recommendations without tort reform. This is probably the most widely-used excuse and my favorite. Whenever a study or guideline advises against doing something, we hide behind the lawyers to justify not changing our ways. The logic goes something like this: if we don’t do the unnecessary test and something bad happens to the patient, then we will be sued. That argument has a few holes in it. We’re not talking about the capricious omission of recommended testing here but avoiding tests for conditions that are very unlikely to be present, tests that may create a problem where one didn’t exist.  In addition, the excuse ignores the other side of the argument. If a patient experiences a complication from a procedure that was not necessary (think contrast reaction during a CT to follow up on an incidental finding) will the lawyers give you a free pass because you were “being thorough?”

2. These recommendations are another step towards rationing. High Value Care, Choosing Wisely, and all of the similar initiatives that preceded them focus on potentially unnecessary testing and procedures that may harm patients without benefitting them. How is not performing a risky test that won’t help a patient (or might even hurt them) rationing?

3. The government should leave us alone and let us practice medicine. This is a variation of the same conspiracy thinking that gave us “death panels.” The “government” is not telling us what to do or not do. The conversation about the appropriateness of testing and procedures started long before the government started talking about the cost of medical care. It is a fundamental part of what we teach medical students – it was in the medical curriculum when I was a student in the 1980s. Our profession is leading the discussion because that is what a true profession does.

4. These recommendations are just another insurance company gimmick to save money. While insurers (and employers, for that matter) are supportive of these efforts and may see a decline in their health care costs, they are not the driving force behind these campaigns. As noted above, the medical profession is leading this movement. When I read or hear this excuse, I sometimes wonder if some of the resistance to these recommendations is driven by concerns about loss of income.

5. I know what my patients need and don’t need a group of ivory tower-types telling me what to do. I call this the “ego excuse.” The physician groups that make these expert recommendations include members from a variety of practice settings, including private practice. And they are recommendations, not commandments. They are a call for all of us to pause and ask the simple questions of “Is this test or procedure really necessary?” and “Will it improve the health of the patient?” This excuse ignores a fundamental principle of being a profession, which is that of self-evaluation of what we do as physicians.

One organization submitted a second list of five items in the recent Choosing Wisely release.  I could probably release a second list of five excuses. Perhaps I will in a future post. Then again, we may even see some of them in the responses to this post.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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