The Medical Professionalism Blog

The Supreme Court’s decision to uphold the Affordable Care Act’s individual mandate as a tax rather than as a permissible use of Congress’ power under the Commerce Clause was a reframing of the legislative issue with real meaning and consequences for the law’s survival.

When the IOM report entitled “To Err is Human” was published in 1999, it changed the quality debate, which was getting little attention, by focusing on how patients were dying and being harmed in unsafe hospitals. Because the report was published by respected physicians, the public and the media started to pay greater attention to the quality and safety of health care. Physicians and hospitals began being drawn to the technical solutions and the culture of patient safety. Ken Shine, former president of IOM, in accepting the 2012 John M. Eisenberg Patient Safety and Quality Award from the National Quality Forum, recalled the tremendous impact of turning the conversation away from simply trying to improve quality to a focus on the very tangible and understandable harm done to patients. “To Err is Human” revealed U.S. hospitals were responsible for between 44,000 and 98,000 deaths annually, or as some put it, the equivalent of a 747 airplane crashing on a daily basis. Clearly, this was unacceptable.

When talking about appropriateness of care — doing the right thing, for the right patient at the right time and doing it effectively — the public rolls its eyes. It’s what they already, and rightly, expect. When the conversation turns to costs of care, there tends to be pushback from the public, physicians and media. This is understandable as it harkens back to the managed care days when the public mistrusted the dual agency of health plans and physicians, appearing to serve the interests of health insurers rather than a focus on the sole interests of the patient.

The Choosing Wisely campaign is focused on getting physicians and patients to have conversations about waste, and the potential harm from tests and procedures that provide little or no benefit in most (but not all) situations. Changing the focus away from appropriateness and cost to waste is equivalent to the IOM’s report focusing not on quality, but on the safety of the patient in the health care system. All can agree that waste is not desirable for patients – it wastes their time, money and potentially puts them unduly in harm’s way.

It is a wonder that a change of a word can alter the course of Federal legislation or an important conversation between patients and physicians and a wider community. Words, when used in the right way at the right time between physicians and patients, can form the building blocks of important conversations that serve as the basis of the Choosing Wisely campaign.