Forty-five procedures doctors don’t think doctors should do
Doctors have many difficult conversations, whether they’re delivering a poor diagnosis or hashing out the best course of treatment. But one of the most challenging discussions, according to physician Lawrence Kosinski, is telling a patient “no.”
There’s a growing consensus that patients and their doctors need to have that conversation more frequently. Wasteful medicine costs the health care system an estimated $700 billion each year, and each unnecessary procedure comes with its own set of health risks. It was those factors that got Dr. Kosinski, who works with the American Gastroenterologists Association, involved in a new initiative called Choosing Wisely, which has partnered with nine medical speciality groups to identify procedures that doctors should not be doing. Each group was tasked with coming up with five specific items they would deem unnecessary.
“What most of them did, when they agreed to sign on, was get all their experts involved and comb through the literature,” says Christine Cassel, president of the American Board of Internal Medicine Foundation, which has coordinated the Choosing Wisely effort. “We also added some rigor by saying it had to be something that is commonly used enough to have an impact, saying it can’t be something done once for every gazillion people. It has to have potential savings, and could cause a potential concern to patients.”
Today, the nine speciality groups that represent more than 375,000 physicians unveiled their recommendations: 45 procedures that, given certain circumstances, doctors should not perform. The American Academy of Family Physicians says its members should not do scans for lower back pain unless certain red flags are present. The radiologists came out against imaging for uncomplicated headaches. The cardiologists want to stop cardiac imaging for low-risk patients.
The goal, now, is to get patients and doctors comfortable with following the new set of recommendations. Cassel hopes to allay both the political and personal concerns that often arise in discussions of changing how medical treatment works.
“Given that this is in Washington, I’m sure we’ll hear some of that rationing discussion,” says Cassel. “The answer, in this case, is not about rationing. This is about preventing patients from being exposed to potential harm from a number of these tests and treatments. This is an important discussion about how we can manage the rising costs of care. Physicians should be thanked for doing their part to get this information out there.”
Getting to the recommendations was a difficult process in itself. Most of the medical specialities involved describe a months-long process where they consulted with various task forces, as well as their general membership, to settle on the five processes they would eliminate.
“We developed initially a list of 37 areas of diagnostic testing that we thought were overused,” says Steven Weinberger, of the American College of Physicians. “We developed this list with both doctors’ opinions, and careful literature searches, to make sure there was an evidence base...then we wanted to cull down the list further.”
But some of the most challenging work might still lie ahead, as the medical groups look to get patients and physicians to comply with the new recommendations. To that end, the American Board of Internal Medicine has partnered with Consumer Reports to get the word out on the new recommendations. The American Association of Retired People and even Wikipedia have also signed on to promote the new information.
The medical groups, for their part, have begun promoting the new guidelines to their own membership. The American Society of Nephrology, whose membership treat kidney diseases, has launched a new website dedicated to the guidelines.
A significant reduction in overtreatment isn’t expected to happen overnight. “This is a cultural shift that will take time,” says Glen Stream, president of the American Academy of Family Physicians, another group involved with the effort. “But overtime, I do think we will see the way treatment gets delivered change.”