Choosing Wisely, or when to say ‘Whoa!’ to unnecessary medical tests and treatments

A potentially game-changing health-care initiative is underway in the USA. The Choosing Wisely campaign is asking top physicians in different speciality areas (e.g. cardiology, obstetrics, radiology) to identify the top five procedures or tests that are routinely ordered by doctors but not supported by research. More than 60 specialty societies have joined the campaign since its inception in 2012.

This campaign is about more than saving money. Unnecessary tests and procedures not only increase health-care costs, but also put patients at risk. Take CT (computed tomography) scans as an example. A single CT scan delivers between 150 and 1,100 times the radiation of a conventional x-ray. According to Scientific American, the National Cancer Institute estimates that the 72 million CT scans performed in the USA in a single year (2007) could cause up to 29,000 future cancer cases. That increase is equivalent to about 2 percent of the total number of cancers diagnosed nationwide every year. In some situations, CT scans are completely appropriate and the benefits outweigh the risks. Many people, however, receive unnecessary CT scans and, along with them, unneeded doses of radiation. 

On a recent perusal of the Choosing Wisely website, I found no less than 57 lists of ‘Five Things Physicians and Patients Should Question’ created by different medical speciality societies. Patient-friendly versions also have been produced in collaboration with Consumer Reports. The Canadian Medical Association has recently joined the effort and will be producing its own Top 5 lists in partnership with nine Canadian physician speciality societies.

Patients are an important part of the campaign because as care partners, they have a responsibility to ask questions about the pros and cons of different treatment options. And sometimes, patients ask for tests and treatments that are not in their best interests. Two classic examples are requests for imaging (X-ray, CT or MRI scans) in the first few weeks of a new episode of low back pain, or requests for antibiotics (which kill bacteria) when all signs point to a viral infection. Research has shown that physicians can be swayed by patient requests for specific tests or treatments even when they disagree, sometimes because they want to please their ‘customer’ and sometimes because they want to avoid potential lawsuits.

Of course, general lists of things to avoid can never substitute for a skilled clinician making decisions in collaboration with the patient. And the American Board of Internal Medicine (ABIM) Foundation, who is funding the campaign, notes that Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.

Resources

Choosing Wisely Campaign website: http://www.choosingwisely.org

Patient-friendly materials: http://consumerhealthchoices.org/campaigns/choosing-wisely/#materials

When to say ‘Whoa!’ to doctors – a great summary produced by Consumer Reports: http://consumerhealthchoices.org/wp-content/uploads/2012/05/ChoosingWiselyWhoaPkg.pdf

Getting what you want from your doctor’s visit

Building from my previous blog post, in which I offered suggestions for choosing your health care team, today I look at a related issue: communicating effectively with your doctor* (*which could mean your physician, nurse practitioner, or anyone else you are seeing for medical advice and help).

Too many patients and too little time

Today’s doctors are in a big hurry. In many cases, doctors are contractually bound to limit the amount of time they spend with each patient (typically ranging from 10 to 15 minutes) for the purpose of meeting total caseload quotas. Doctors who do not see the number of contractually stipulated patients can be penalized financially or in other ways. Although this system has been criticized heavily from all sides (not least of all, by the doctors themselves), it is the reality under which many health care providers are now seeing patients.

Get clear in your own mind

If you have only 10-15 minutes with your doctor, you need to be thoughtful and organized about your time. You also need to realize that it is as much—or arguably more—your job, as opposed to your doctor’s job, to ensure that you get what you need from your appointment. 

You must plan in advance. First, define what you really want from the appointment. If you are seeing your doctor for a rash, for example, you might want to know whether it’s contagious; or alternatively, you might want a prescription to stop the itching; or maybe you really just want piece of mind that it’s not bed bugs from your recent trip to Paris. The point is: get clear in your own mind what will make the appointment a ‘success’ for you.

Write it down

It never fails to amaze me how often smart, capable people fail to go to their doctor with a written list of issues and questions. (They also fail to bring pen and paper or any type of a recording device, to take note of what is discussed and recommended. But that is a different topic.) With a written list, you will be less likely to become distracted and more likely to get what you want from the appointment. 

Communicate succinctly and effectively

Once you are clear about why you are at the doctor’s office, communicate your goals clearly and repeatedly, before and during your appointment. The essential formula is: “I am here for X issue or problem, and I would like your help via Y action.” Tell the medical assistant or nurse who brings you into the exam room, and repeat it to the doctor. If you plan in advance, it should take you no more than 10 seconds to communicate this information.

For example: “I am here today about this rash. I would like to know if it’s contagious.” Or, “I have been more short of breath lately, and I’d like the doctor to go over my medications and see if there is anything else that can be done to address my asthma.” Practice in advance.

Dealing with multiple issues in one visit

If you have multiple issues you want to address within a single appointment, you might consider starting by saying something like, “I have four things on my list to discuss with you. I am not sure you will have time for all of them. The things I want to cover, in my personal order of priority, are a) a new rash on my chest, b) my ongoing knee pain, c) my ongoing neck pain, and d) new shortness of breath since yesterday.”

Be realistic

You must be realistic about what can be covered within the allotted time. If you don’t know how much time is available for your appointment, ask in advance or while there. Prioritize your list and if necessary, schedule a follow-up appointment to deal with topics that could not be covered fully.

In some cases, your priorities will not match the priorities of your doctor. For example, it is highly likely that any doctor hearing the list outlined in the scenario above would deal first and foremost with your new shortness of breath. That’s because shortness of breath is potentially a life-threatening condition and might indicate a major medical event in progress, such as a heart attack or a blood clot. In situations like these, you need to trust that your doctor is using his/her expertise to reprioritize your list for your overall health.

Finally, it is important to understand that competent doctors practice within the scope of evidence-based medicine, even if that means denying you something you think you want. Good-quality doctors, for example, will not prescribe an advanced imaging test for acute, uncomplicated low back pain, nor will they prescribe an antibiotic for a presumably viral infection. They should, however, explain to you the reasons why this is the case.

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In summary, getting what you want from your doctor’s visit is up to you. Plan in advance, write it down, and communicate clearly.

Resources

Before Your Appointment: Questions Are the Answer. Agency for Healthcare Research and Quality. http://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/questions-before-appointment.html

How Can You Get the Most Out of Your Doctor's Appointment? Center for Advancing Health. http://www.cfah.org/prepared-patient/communicate-with-your-doctors/getting-the-most-out-of-doctors-appointment