Choosing Wisely to Avoid Harm

| 28 October 2013

Five Things You Can (Not) Do to Improve Patient Care

“Excellence is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives - choice, not chance, determines your destiny.” ― Aristotle Do you recall the day in medical school you were taught Ockham’s razor (seek a single explanation for a collection of symptoms)? It was likely the same day you learned the Hippocratic axiom, Primum non nocere (First, do no harm). I would venture you learned both these lessons early in first year as you launched your voyage as Physician.

fig 1

Speaking of voyages, let me suggest that the medical profession is like the crew of the Starship Enterprise. The Enterprise’s crew was well-intentioned in pursuit of its Mission - to go where no man has gone before - but were often in violation of their Prime Directive - no interference with the internal development of alien civilizations. Likewise, we physicians are committed to our Mission: diagnosis guided by Ockham’s razor-the law of etiologic parsimony. However, it has recently become apparent that we too are violating our Prime Directive: that admonition against doing harm. No, it cannot be! How are we in violation? What is the evidence for this allegation? Well, it can be that the problem is occurring despite our good intentions. The violation is insidious: over use of diagnostic testing in a manner that does not support our Mission and which violates the Prime Directive, ie. hurts patients. To put our failing into clear language (no not Klingon,) we are not Choosing Wisely. As individual doctors and as a profession we are ordering lab tests and diagnostic imaging that offer no benefit and may cause harm. The nature of harm varies. Sometimes, it is turning the patient into a pin cushion through serial blood testing, and sometimes it is exposing them to radiation through CT scans. These unnecessary blood tests and imaging not only expose the patient to risk and clog the system, but also often yield incidentalomas. Incidentalomas - think incidental pancreas and thyroid nodules and troponin levels that are just above normal - are findings that were not sought and which often have no prognostic importance but which all too often launch further testing causing patient anxiety and congesting the system. The consequences of this? Patient harm. What are we to do? If you’re like me, and I know I am, you don’t like other people dictating your medical practice. You monitor your practice carefully and choose tests judiciously. Of course, you will concede, you have seen cases where a colleague ordered daily electrolyte measurements for 2 weeks on an inpatient with stable electrolytes, “just to be safe,” or ordered annual exercise stress tests to ‘monitor’ a patient with stable coronary artery disease. It turns out that while we as individual practitioners are often decisive, thoughtful and parsimonious in our use of diagnostic testing, as a group we have enough sloppiness and automaticity in our practice that a lot gets ordered that is unnecessary. So who is to make the change? You are at the bedside or in the clinic, You have the responsibility to diagnose and manage your patient. The idea of administrative policies limiting your testing options is anathema! Fortunately that is not the proposed solution. You are the solution.

The ABIM Foundation recently championed this issue and is trying to get the crew of our Starship back on course. In their grass roots initiative is called Choosing Wisely. It encourages "physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.” More than 50 specialty societies have already joined the Choosing Wisely campaign. These societies, representing half a million MDs, have developed lists of Five Things Physicians and Patients Should Question. These lists are meant to inspire physicians to think about what they order and empower patient’s to participate in their care and to not assume more is better, when it comes to testing. These lists, provided by each specialty, should inform patient and physician conversations and help eliminate unnecessary tests and procedures thereby improving care. Here is an example from the Society of General Internal Medicine:

Do these recommendations help us with the Prime Directive? Well, number one would certainly make the finger tips of a lot of patients less sore, numbers 2 and 3 would reduce waiting lists by unclogging our clinics, allowing room for appropriate care, number 4 would not only do this but save the sick and elderly from uncomfortable testing. Number 5 would undoubtedly reduce central line-associated infections - a major problem in modern hospitals. These five suggestions from one society would do a lot of patients a lot of good. Imagine the benefit of successful initiation of similar wise choices by 50+ societies and the physicians they represent.

Choosing Wisely is not just targeted at physicians; the strategy is one of informing the patients to make them partners in their care. Patients are being given this information, through outlets such as Consumer Reports:

Doctors may feel pressured by patients or medicolegal concerns to do comprehensive testing. Partnering with patients in reducing excessive testing will hopefully assist us in conversations about why we are selective in our testing. Among the common practices called into question are routine diagnostic imaging for headaches and short-term lower back pain, prescription of antibiotics for sinusitis, annual electrocardiograms for low-risk, symptom-free patients and annual Pap tests in low risk populations.

There is a major interest in Choosing Wisely in Canada, led by my colleague, Head of Medicine at the University of Toronto, Dr. Wendy Levinson. In a recent discussion with Wendy at the annual meeting of the Canadian Association of Professors of Medicine she emphasized that Choosing Wisely is about preventing harm to our patients, not saving money. Dr. Levinson notes that excessive testing generates more frequent false positive results. “False positives are a kind of harm. It can be harm psychologically, and physically.” There are of course financial consequences to Choosing Wisely, however they are positive. The financial savings that would undoubtedly accrue are a pleasant side effect of doing the right thing for patients. Nonetheless anything that is beneficial to patient care and saves money is worth considering. A quick look at the trends in cost of health care supports the need for paradigm shifts that will create a downward inflection (see Figure below).

OECD 2013: Courtesy of Dr. Levinson

The Canadian Medical Association (CMA) has embraced Choosing Wisely at its recent meeting in Calgary. With our own Dr. Chris Simpson, Chief of Cardiology, at the helm of the CMA I expect to see this program blossom in Canada.

Dr. Simpson notes, "Physicians are really embracing the principles behind Choosing Wisely. It's all about doing the right thing for patients and avoiding the harm that can come from unnecessary testing. There is also a sense of responsibility in the physician community around stewardship of our limited health care resources. Facing limits on what society can afford, it is up to us to define and enhance medical appropriateness. Let's do more of what works and what is safe; and less of what is unnecessary and done ‘just in case’. Society expects us to lead the way, and the physicians of Canada intend to do just that."

Dr. Roy Illan, Assistant Professor and Head of the Department’s Patient Safety Committee noted, “While Choosing Wisely objectives would be likely accepted by many healthcare providers, and patients, it is crucial to acknowledge that the choices of individuals are heavily influenced by the context, local culture and multiple additional factors. It has been shown repeatedly that quality improvement initiatives should not rely exclusively on education because, perhaps surprisingly, education (alone) is ineffective in enacting behavioral change; therefore, each specific target, such as avoiding non-essential PICC insertions, should be addressed through effectively treating relevant system factors.” So, the next time you find yourself ordering “daily electrolytes”, serial troponins, venous blood gases, an annual physical examination or a surveillance treadmill….think of Aristotle (or Gene Rodenberry) and Choose Wisely!

Gene Roddenberry (in brown) and the crew of the Starship Enterprise in front of the Space Shuttle Enterprise, 1976

Dr. Levinson will be giving Medical Grand Rounds at Queen’s University at 0745 on Thursday March 20, 2014 in Etherington Auditorium. I hope to see you there. In the meantime, Choose Wisely and Prosper!