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I recently attended a presentation by Mark Bonchek of thinkORBIT where I was inspired to reflect on the past three years of Choosing Wisely® and how the campaign reflects a cultural shift both in society at-large and in the way businesses operate. This shift has roots in self-determination theory, complexity theory, co-creation and digital strategies like those espoused by Bonchek.
1) Moving from managed processes TO ones with minimal rules/principles and maximum flexibility
Choosing Wisely gave societies four simple rules to guide them through the creation of their lists of tests and procedures. The recommendations needed to be:
- frequently done or costly;
- within the control of the specialty; and,
- created using a transparent process.
2) Moving from control TO autonomy and respect
Choosing Wisely respected the societies’ unique knowledge and mastery of their particular specialty areas, and empowered them to develop their own credible processes for creating their lists.
3) Moving from hierarchical/top-down relationships TO non-hierarchical, bottom-up ones
In the absence of a centralized authority or bureaucracy, more than seventy societies have joined the campaign. They, in turn, solicited the opinions of many physicians in their society, getting them to buy into the campaign during the process.
4) Moving from product creation TO a platform
The Choosing Wisely website contains the lists of recommendations, and resources are available on both the ABIM Foundation and Consumer Reports sites. All parties, including regional health collaboratives, medical associations and delivery systems, use the information on these websites to help them develop their own local strategies for implementing the recommendations and changing attitudes.
5) Moving from one-way communication TO community- and relationship-centered communication
The Choosing Wisely campaign is comprised of over one hundred organizations united by a single purpose. They communicate with each other through learning networks, bulletin boards, newsletters and many websites. This supportive, respectful, relationship-centered community is key in the promotion of shared decision-making conversations between patients and physicians.
6) Moving from competition TO collaboration and co-creation
Rather than having “expert” or oversight organizations develop the lists, the Foundation urged the societies to encourage its members to “co-create” their lists. Volunteer physicians associated with the campaign reviewed the recommendations primarily for clarity. Particularly in the early phase of the campaign, specialty societies worked collaboratively to design the format of the two-page recommendation sheets and the information included (e.g., conflict of interest disclosures).
Physician empowerment and leadership is what is attracting many to this campaign. I think these principles could be applied to all types of desired physician engagement strategies. It is a new culture and a new way of doing the work that is producing such engagement. Organizations that are implementing Choosing Wisely are also using the above principles to design their interventions with great results.
It’s a new dawn – it’s a new day.
A recent article challenged the Choosing Wisely recommendations around routine stress testing before low-risk surgeries. The article, “Stress Testing Before Low-Risk Surgery: So Many Recommendations, So Little Overuse” suggested the campaign’s partners focus on services with “high baseline rates of inappropriate care.” In her Editor’s Note in the same issue, Rita Redberg, MD, called for the specialty societies to create bolder recommendations about tests and procedures that patients and physicians should question. Both articles agreed that societies should adhere to the campaign’s charge to reduce unnecessary care.
One of my relatives has metastatic cancer. He has several tumors in his body, one of which measures five centimeters. Two chemotherapy regimens have failed to beat back the disease. Yet, when he’s not in treatment and has no pain, he is able to go about the daily activities of his life, even going to work. If it wasn’t for his hair loss due to the chemotherapy, you wouldn’t even know he is seriously ill.
After consulting with his siblings and loved ones, he recently entered a Phase 1 clinical trial. The clinical trial is testing an immunomodulator, based on the theory that the body’s natural immune system can be recruited to act against the cancer cells.
Regular readers of this blog know I support the adoption of lean methodology to eliminate health care waste. So, it was with great pleasure that I accepted an invitation from Oregon Health & Science University’s (OHSU) Chief Medical Officer (and my friend), Chuck Kilo, to visit his academic medical center and speak about Choosing Wisely®. OHSU has been a proponent of the lean philosophy for several years and I was excited to learn how the organization was applying it to make improvements in quality, safety and professionalism.
Physician and patient organizations alike have increasingly emphasized the importance of improving value in health care and reducing unnecessary (and potentially harmful) care. Choosing Wisely®, the ACP’s High Value Care initiative and other programs have successfully stimulated interest and conversation, but what actual steps to take to improve value in hospitals is not entirely clear.
How can we move from interest to action to improve the quality and appropriateness of the care we provide to our patients?
We’ve feted the new year. Now it’s time to assess that list of resolutions.
Through the Choosing Wisely® campaign, Costs of Care and the ABIM Foundation have resolved to continue promoting high-value care by reducing waste and overuse in health care in 2015. As such, we’ve launched the second Teaching Value and Choosing Wisely Challenge to identify the most promising innovations and bright ideas in medical education that can be successfully implemented on a larger scale.
We all talk about “patient-centered care” without having a clear vision or definition of what it is or means. Thus I was honored to have the ABIM Foundation be one of the many organizations the Gordon and Betty Moore Foundation and the American Institutes for Research (AIR) convened to develop a roadmap for patient and family engagement in healthcare practice and research. This work will help pave the way for true patient-centered care for the future.
A section of the tabloid, US Magazine, called “Stars – They’re Just Like Us”, shows pictures of celebrities doing mundane activities like walking the dog or taking out the garbage. This helps to remind us that, just like the average Joe, they walk their dogs and take out the garbage and— because they are people, too—might even need medical treatment from time to time. Unfortunately, some doctors treating celebrity patients don’t see them “just like us.”
Jeffrey Kullgren, MD, MS, MPH, a general internist and researcher from VA’s Center for Clinical Management Research and the University of Michigan Medical School has a method for implementing Choosing Wisely® recommendations. He relies on a behavioral economics technique referred to as “precommitment” which, in this instance, calls upon physicians to make choices rooted in medical professionalism.
How is it that when the health care system is going through needed and positive changes, people like Pamela Hartzband and Jerome Groopman write an opinion piece in The New York Times in which they profess a longing for the “good old days” before measurement? For a moment, let’s go back to those old days. They weren’t as good as they think they were.