There is a campaign underway to help consumers understand the risks and benefits of selected procedures commonly used in care. The Choosing Wisely campaign is a collaboration of more than 70 professional organizations whose intent is to bring best evidence into the public spotlight in order to help consumers take a more active role in decisions that affect their health and safety.
By focusing on the patient-clinician relationship, the goals of this national initiative are as follows.
“Choosing Wisely aims to promote conversations between clinicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary”
Such a critical (and some may say noble) concept is proving to be a hard sell to the American public. Studies are emerging that point to difficulty on both the clinician and patient sides of the decision equation.
We are a nation that expects a great deal from life. The media, entertainment industry, and ever-present advertisements for a “cure-all” medication drive our need for products and services. It is one thing to want the latest and greatest piece of technology for our home; it is quite another to consider screening tests or other interventions for our own bodies.
We also must confront the fact that the healthcare industry has fostered this thinking by not effectively adopting best evidence. Here are three examples from the Choosing Wisely list of evidence-based recommendations for clinicians.
- Offer PSA screening for detecting prostate cancer only after engaging in shared decision making. —American Urological Association
- Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it. —American Academy of Nursing
- Don’t place women, even those at high-risk, on activity restriction to prevent preterm birth. —Society of Maternal-Fetal Medicine
Sadly, today one could go to an office practice and be offered PSA screening without shared decision making. Likewise, regarding examples 2 and 3, we still see hospitalized patients awakened without cause and pregnant women placed on bed rest or other activity restrictions when preterm labor is possible. Yet research shows these interventions do not improve outcomes and in fact may cause harm.
A Long Road Ahead
Culture does not change easily. The practice environment in healthcare is central to the culture change that is needed. But let us not forget that this is the 21st century, and consumers/patients have a key role to play in their own care. A survey of physicians conducted by the American Board of Internal Medicine (ABIM) demonstrated that when patients insist on a procedure or service despite a discussion of risk and benefit, 53% of doctors will order it.
This is troubling indeed because some of those patients may have an unintended consequence as a result of insisting on the intervention. The examples are many. If you have ever attempted to explain to a woman with no risk factors for breast cancer that the broad use of mammography has generated harm, you are likely to face a barrage of objections about how women should not be denied something that may save their life.
Can clinicians and consumers work together to bring a new evidence-based face to decisions about care, or will these be made for us by the government as costs continue to climb?