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The Medical Professionalism Blog

Choosing Wisely®: Reports from the Field – Culture or Accounting?

Since the launch of the Choosing Wisely campaign in April, I’ve received interest from a number of health care systems that want to learn more about the effort. They typically fall in to two camps:

  • One group sees the importance of attitudinal and cultural change. They see the power of conversations between patients and physicians without interference from other parties of interest – insurance companies and the government.
  • The other tends to focus on technical aspects of putting specialty societies’ recommendations into practice. They want to know how to measure the changes in the use of unnecessary tests and procedures, taking into account the “red flags.”  They think about the strategies for behavioral change, including feedback, addressing outliers, building the recommendations into EMR’s medical decision-making and financial incentives.

I think it’s a missed opportunity for organizations to not address attitudes as the first priority. Somehow organizations continue to consider culture and attitude as non-essential, something too soft to think it will achieve their ultimate goals.

But physician attitudes dictate how they practice and how well they will adhere to organizational strategies aimed at behavior change. The changes in attitude we aspire include physicians accepting professional responsibility for the appropriate use and cost of health care resources and willingness and ability to speak with patients about unnecessary care and the risks of non-beneficial. This will require physicians to make time to have honest and trusting conversations with their patients about benefits and risks of tests and procedures and the uncertainties inherent in medical care.

Leaders at the Cleveland Clinic, and a broad network of community physicians in the Cleveland area collectively called the Quality Alliance, have expressed interest in the Choosing Wisely campaign.

Dr. Tarek Elsawy, Chief Medical Officer of Community Physician Partnership & Quality Alliance, states, “Attitudinal changes will be the most important and longest-lasting changes. My hope is that the Quality Alliance will be able to spearhead the efforts of our physicians in accepting the crucial task of being a key guardian of our health care resources.”

What was remarkable was that leadership at the Cleveland Clinic realized the tests and procedures recommended by the specialty societies taking part in Choosing Wisely were a vehicle for change in medical decision-making, and that attitudinal change can be pervasive throughout daily medical decisions.

Behavioral changes are likely to focus on a range of tests and procedures. The Choosing Wisely campaign intends to have wide ranging conversations between physicians and patients about the right care: no more, no less, just the right amount, at the right location and performed effectively, without harm. Implementation should be joined with changes of attitudes and culture.

The good news is that there are many health systems focused on exploring ways to implement the recommendations from the specialty societies involved in Choosing Wisely.  But the bigger question remains: Will their focus be on culture or on accounting…or both?

2 Comments to Choosing Wisely®: Reports from the Field – Culture or Accounting?

  • June 27, 2012 at 3:32 pm | Permalink

    Eric- Thanks for your comment. Your patients appreciate your respect for their time and not putting them through the slippery slope of medical technology. Thank you for your professional integrity.

  • Eric Waffner's Gravatar Eric Waffner
    June 26, 2012 at 7:34 pm | Permalink

    Unfortunately doctors are often reimbursed for these unnecessary tests and there is the perception that they increase their liablity risk by not testing. In training I was taught the value of a yearly ECG. About 8 years ago I looked hard at the value this test provided and determied that in the absence of symptoms the ecg primarily improved my income and not my outcomes. I stopped performing the test but found my income droped by about $5000.00. This gave me pause, fortunately I stuck to my original decision, but it made me realize that until medicine pays for quality care over quantity of care these practices will continue.

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