A guest column by the American College of Physicians, exclusive to KevinMD.com.
In earlier columns I wrote about two initiatives to promote physicians providing the best possible care by reducing or eliminating the use of tests or treatments that have little or no value to patients. They are ACP’s High Value Care and ABIM Foundation’s Choosing Wisely. I also wrote about some of the barriers to putting the two programs’ recommendations into practice, specifically how physicians and other providers can get in the way. This month I will discuss additional challenges to doing what I believe is the right thing for our patients.
I’ve been trying to practice effective care for years, even before these initiatives put the spotlight on overuse and misuse of interventions. But it hasn’t been easy. Of all of the obstacles, the biggest one is lack of time. High value care is not just about stopping things that we’ve been doing for years; it is also about starting to do things that we haven’t been doing. However, there does seem to be more of the former than the latter. Explaining why I’m no longer ordering something seems to take longer than explaining why I am starting to order something, especially if it is a test or treatment that was once considered routine or that other physicians are still doing.
Not only do I have to spend time explaining that it isn’t necessary, but also why it was necessary before and why a spouse or friend is still getting it. The fact that our society is biased towards “more is better” makes it even more challenging to discuss this in a limited amount of time. (One exception seems to be when the procedure in question has a high out-of-pocket expense or is very uncomfortable — that discussion is easier).
The patient’s degree of health literacy and level of education can make these discussions even more difficult. Explaining the difference between correlation and causation, the effects of prevalence, sensitivity, and specificity on the usefulness of a test, or the harms of overtesting in just a few minutes is hard work. Even highly-educated persons struggle with many of these concepts. Moreover, not only must I deal with what patients do not know, but also with what they think they know, since whatever I say is vetted against their experiences, the wisdom of “Dr. Google,” general media health “experts,” and anyone else who thinks that they can offer a medical opinion.
One challenge that I did not expect and find somewhat disheartening is a high level of cynicism. One of the more ridiculous responses to my efforts to provide high value care that I’ve heard is that it is all because of “Obamacare.” I find that especially ludicrous given that the principles behind “High Value Care” and “Choosing Wisely” are not new. I was taught them in the mid-1980s when I was a medical student (and no one back then had ever heard of Barack Obama). Patients blame insurance companies from time to time during these discussions, and a few have questioned whether I have an ulterior motive (which I address by pointing out that under the current system, many of my recommendations actually cost me money, since I’m part owner of my group’s lab and imaging center and would benefit from more testing, not less).
How does a physician or other health care provider overcome these obstacles to practicing high value care? Understanding and anticipating the barriers is helpful, of course. For many of the recommendations, professional societies or medical journals have patient information materials. Consumer Reports also has a collection of High Value Care and Choosing Wisely resources, which are not only easy to understand but add the credibility of a non-medical authority to the discussion.
Rehearsing “talking points” is also helpful, but these have to be tailored to the level of health literacy, education, and cynicism of each patient. Building strong relationships with patients so they trust that you are acting in their best interest is important for many reasons and facilitates these discussions on what are (and are not) appropriate tests and treatments.
I believe that having more time to discuss testing and treatment with patients would support this effort more than anything else. That is easier said than done. By delegating to others such as medical assistants or nurses some of the tasks that the physician used to do, team-based care frees up a few minutes in a visit that can be used to discuss these issues. However, that alone is not enough. New payment systems that value time spent with patients rather than the number of patients per day will move us closer to our goal.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.