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The Medical Professionalism Blog

Inspired in Washington

I was honored to keynote the recent Choosing Wisely Summit held by the Washington State Choosing Wisely Task Force. Comprised of the Washington Health Alliance, Washington State Medical Society and the Washington Hospital Association, the Task Force has been a leader in developing community collaborations focused on the measurement and implementation of the campaign.

I’ve developed a bit of a routine with my Choosing Wisely® talks that I think helps set the tone for the room and underscores the importance of our work to reduce unnecessary or overused tests and treatments. Given the makeup of the audience, I was particularly interested in seeing how this technique would play out.

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My Lean and Mean Physical Exam

More than two years ago, the Society for General Internal Medicine (SGIM) released its list of Choosing Wisely® recommendations, which included advising against performing routine general health checks for asymptomatic adults. The rationale behind the recommendation was that “regularly scheduled general health checks without a specific cause, including the ‘health maintenance’ annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.” Unsurprisingly, controversy ensued among primary care physicians who feared that the patient-physician relationship would be harmed by the lack of an annual physical.

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Choosing Wisely® – Building Bridges Across Care

When the ABIM Foundation launched the Choosing Wisely campaign, we created a set of operating principles for our society partners and gave them guidelines to help them develop their lists. Among these guidelines was a stipulation that recommendations needed to be within the control or purview of that specialty. Each society was asked to take responsibility for waste or overuse in its own domain and, to date, more than 70 societies have created and published over 400 recommendations doing just that.

Over the past three years, our partners have worked diligently to educate their members on these areas of waste through journal articles, education sessions and member communications. We’ve been heartened by the positive response among clinicians in adopting and adapting these recommendations into their practices through a variety of implementation initiatives.

While we were hopeful societies would join us in Choosing Wisely and develop lists of five areas of overuse, we’ve been pleased to see many come back with additional lists of five more, and in at least one case—the American Academy of Family Physicians—a third set of five.

As the library of Choosing Wisely recommendations has grown, the frequency of society list releases has understandably slowed. Yet we are beginning to see the lists and recommendations used in new and innovative ways that I think represent some of the future of the campaign.

The American Academy of Neurology (AAN), in an endeavor to “increase neurologist awareness and inform future efficiency efforts,” recently published an article identifying 74 additional recommendations from across all Choosing Wisely society lists.

AAN identified several areas of overlapping recommendations from societies, as well as gaps in what has been published. AAN found 12 recommendations relevant to neurology that appeared on multiple society lists. These represent areas of consensus across the profession and serve to strengthen the case that they are overused or unnecessary.

Perhaps more important, though, was the identification of gaps in the recommendations. The authors specifically point to neurologic areas that haven’t been covered by the campaign, such as subspecialties of movement disorders or neuromuscular diseases, as opportunities to examine the evidence and determine if new recommendations are needed, either by AAN or others.

I commend AAN for looking at the Choosing Wisely recommendations in their entirety rather than as defined by specialty society and identifying additional areas neurologists should know about. As the authors wrote, “Knowledge of these recommendations is important in delivering efficient neurologic care and should be used to jumpstart patient and physician communication regarding the need for these tests and treatments.”

Choosing Wisely has always been about the conversation between clinicians and patients. I look forward to and encourage additional efforts like the one from AAN to look across the spectrum of all Choosing Wisely recommendations and create new ways of disseminating information to clinicians. By increasing awareness and understanding of what tests and treatments are unnecessary, we’ll help clinicians be better prepared and informed to join their patients in these critical conversations about their care.

A Sacred Moment Ruined

On July 28, my wife’s brother, Marcos, died from cancer at the age of 58. He died at home under hospice care and was heavily sedated over the last weeks of his life. Marcos had undergone two chemotherapy regimens and one experimental treatment. His doctor was exemplary – she provided the best treatment options yet remained realistic about outcomes, she had excellent communication skills and provided comfort care when treatments were no longer an option. When Marcos took his last breath, he was surrounded by people who loved him dearly: his wife, two sisters, one brother, his best friend and me. Hospice care was excellent – there was communication on what the dying process might bring and how best we, the family, could comfort Marcos at the end. We all felt supported by the hospice nurses’ compassion and ample technical skills that enabled them to make independent decisions coordinated with the agency physician and oncologist.

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Docs Call Foul on Mark Cuban

An article in Forbes magazine entitled “Mark Cuban Doesn’t Understand Health Care” highlighted a series of tweets sent out by Mr. Cuban telling his 2.8 million followers to obtain quarterly blood tests in order to “have a baseline of your own personal health.” The Forbes piece focused on the “problems with Cuban’s argument” and included an exchange between the businessman and Charles Ornstein, a Pulitzer Prize-winning reporter with ProPublica who challenged Mr. Cuban to provide evidence that these tests have any benefit to patients.

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SOAP-V: Applying High-Value Care During Patient Care

This guest post was submitted by winners of the ABIM Foundation and Costs of Care Teaching Value and Choosing Wisely Challenge. 

“It’s important to teach the principles of cost-conscious, high-value care, but how do we enable our medical students to actually practice it?” This question gripped our group of clinician educators gathered at the Millennium Conference on Teaching Value-Added Care in 2013. Students needed authentic opportunities to apply High Value Care (HVC) knowledge and practice HVC skills. Additionally, our own institutions needed to prepare for the shift from fee-based care to value-based care. We had a big idea: medical students would not only practice HVC, but they would also serve as change agents at our teaching hospitals to encourage HVC.

We acknowledged many obstacles to teaching students about HVC. Most clinical faculty who teach medical students during patient care delivery have not been trained in HVC. “Value” frequently does not enter the busy clinician’s mindset and consequently, students may not observe HVC being modeled. Our current health care environment emphasizes action, through sophisticated tests and invasive procedures, without meaningful consideration of the risk of harm to patients. Given the rapid pace of clinical care, it is no surprise that the clinician educator would find it challenging to remember to teach HVC during patient care activities. We needed to develop a method to remind students and their teachers to consider value and to embed that process in their workflow.

SOAP-V emerged as a modification of traditional “SOAP” presentation (Subjective-Objective-Assessment-Plan), adding “V” for value. This framework creates a cognitive forcing function to promote discussion of HVC during patient care delivery. The SOAP-V model prompts students to consider several questions:

1) Before choosing an intervention, have I considered whether the result would change management?

2) Have I incorporated the patient’s goals and values, and considered the potential harm of the intervention compared to alternatives?

3) What is the known and potential cost of the intervention, both immediate and downstream?

In the summer of 2014, we collaborated to implement SOAP-V for third-year medical students during their internal medicine clerkships at our home medical schools: Penn State College of Medicine, Harvard Medical School and Case Western Reserve University School of Medicine. We developed HVC teaching materials, including a video, PowerPoint presentation and role-playing exercise that could be taught within 45 minutes. The students received a SOAP-V card and the HealthCareBluebook.com Web address to research costs, and then used SOAP-V during patient rounds in the hospital.

Biweekly surveys and direct observation confirmed that third-year medical students are using the SOAP-V tool at our medical schools. Trained students report increased comfort in initiating discussions about unnecessary tests or treatments with their teams, increased power to address the economic health care crisis and increased consideration of potential costs to the health care system when making clinical decisions compared to the control group of students who did not receive the SOAP-V intervention.

By using SOAP-V, medical students can demonstrate the application of HVC on teams to both resident and attending physicians. Our next steps will be to gauge whether resident and faculty attitudes about HVC have changed, as well as to embed SOAP-V in other clerkships, and to promote the use of the SOAP-V tool within corresponding residencies.

Drs. Eileen Moser and Susan Glod from Penn State Milton S. Hershey Medical Center; Drs. Sara Fazio and Grace Huang from Harvard Medical School; and Dr. Clifford Packer from Case Western Reserve University and the Louis Stokes Cleveland VA Medical Center, modified the traditional SOAP note template to include a discussion of value. The team was a winner of the 2nd Annual Teaching Value and Choosing Wisely Challenge. 

Choosing Wisely: It’s a New Dawn, It’s a New Day

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;
  • evidence-based;
  • 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.

Choosing Wisely®: From Engagement to Implementation

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.

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Information Can Empower the Seriously Ill in a Powerless Situation

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.

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Oregon Health & Science University: A Journey into Lean Health Care

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.

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