• The author of a new JAMA Internal Medicine commentary discusses how physician specialty societies are dealing with costs. He notes that addressing cost is part of the Physician Charter, which calls on physicians to “be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care.”

• In Supporting students in self-regulation: Use of formative feedback and portfolios in a problem-based learning setting, researchers reported that first-year medical students incorporated formative feedback from peers and students to address areas of improvement in their professionalism behaviors.

• A recent survey of third-year medical students at Imperial Medical College in London examined students’ perceptions of professionalism. The authors found that the “most commonly cited aspects of professionalism by students in this study were confidentiality, good medical knowledge and practical skill. Students also cited promptness, hygiene and appearance as being important, although these factors are rarely cited in the literature.” In addition to their formal coursework on professionalism, students cited their observations of physicians, interactions with patients, the media, and their parents as important influences on their perceptions of professionalism.

A Choosing Wisely Rubik’s Cube might include the need for:

• Recognition of quality and better outcomes of care by reimbursement systems and financial incentives
• Tort reform
• Payers to stop micro-managing physicians with prior authorizations and the like
• The necessary infrastructure and competency of physicians and administrators in stewardship of resources
• Data to know if changes in resource use has occurred
• Figuring out what to do with current investments in equipment and facilities when utilization is appropriately decreased and diagnostic and treatment equipment are at less than full capacity.

I frankly agree that there are challenges facing us. While the list above comprises things that I believe could aid the adoption of the Choosing Wisely recommendations and philosophy, there are five things troubling me:

1. What happens in the meantime when I need care and I only want care that is needed? Do I have to wait until all these problems are solved?
2. Don’t physicians and delivery systems have it in their power to eliminate unneccessary tests and procedures?
3. What will happen to the public trust of physicians and health care institutions when the public discovers that outside factors are interfering with the professional commitment to the primacy of the patient and quality of care, key principles of the Physician Charter?
4. Why aren’t physicians doing the right thing to prevent, heal and restore the health of their patients? Isn’t that the calling of the profession?
5. Will our country have to continue to suffer the ill effects of high spending on health care (without better health outcomes) to the detriment to our educational system, infrastructure and national security?

I never solved Rubik’s Cube and I obviously don’t like the analogy. Finding a solution to this puzzle is personal because soon I will need more health care and don’t want unneeded and wasteful care. I can’t wait for all these problems to be resolved before actions are taken to solve some of the problem.  The time is now to address waste and continue to work on other changes needed in the system. The Choosing Wisely recommendations are straightforward and relatively easy to implement compared to other more complex changes needed. Although we might not be able to complete the puzzle, we can at least get started putting some of the pieces together right now.

• Researchers interviewed medical students to assess the impact of Clinical Reflection Training (CRT) on how students handled professional dilemmas. Students reported that CRT reduced their stress, improved patient care and was a useful part of professional development.
• On The Health Care Blog, a primary care physician discusses the importance of “Testing Wisely” and shares his rules of preventing unnecessary tests and procedures.
• The American Academy of Family Physicians, the American Congress of Obstetricians and Gynecologists, and other professional groups issued a letter to hospitals providing maternity care urging them to eliminate non-medically indicated deliveries before 39 weeks’ gestation as part of the HHS Strong Start Initiative. According to AAFP Executive Vice-President Douglas Henley, “Strong Start allows the AAFP to spread the message from the Choosing Wisely campaign to another important target audience.”

Throughout 2012, Foundation staff tracked the medical professionalism literature, which was comprised of more than 100 articles. After an initial review by ABIM Foundation staff, our thoughtful and thorough selection committee—whose members included a consumer representative, a medical student and several physicians— awarded prizes to three journal articles in the categories of Commentary/Perspective, Medical Education and Training and Professionalism in Practice.

Congratulations to our winners!

• The Commentary/Perspective prize was awarded to “Perspective: The Negativity Bias, Medical Education, and the Culture of Academic Medicine: Why Culture Change is Hard,” by Julie Haizlip, MD, Natalie May, PhD, John Schorling, MD, Anne Williams, MA, and Margaret Plews-Ogan, MD, MS, published in Academic Medicine. The committee praised this as “a rare piece that provides a new framework and a new language for understanding a problem that has long been recognized.” The negativity bias refers to the phenomenon of individuals remembering negative events and emotions more strongly than positive ones. The authors describe how medical education settings reinforce the negativity bias, which may undermine the Charter’s principles and commitments to the primacy of patient welfare, improving quality of care and  commitment to professional responsibilities, among others.
• In the category of Medical Education and Training, the prize was awarded to “A Multi-institutional Study Exploring the Impact of Positive Mental Health on Medical Students’ Professionalism in an Era of High Burnout,” by Liselotte N. Dyrbye, MD, William Harper, MD, Christine Moutier, MD, Steven J. Durning, MD, David V. Power, MD, F. Stanford Massie, MD, Anne Eacker, MD, Matthew R. Thomas, MD, Daniel Satele, Jeff A. Sloan, PhD, and Tait D. Shanafelt, MD, published in Academic Medicine. Committee members viewed this large, multi-site study as advancing our understanding of medical students’ burnout and how positive mental health may mitigate burnout’s effects. Burnout is common among medical students and physicians. If left unaddressed, it can have serious consequences for the primacy of patient welfare,  professional competence, commitment to professional responsibilities and other tenets of professionalism.
• Finally, the Professionalism in Practice prize was awarded  to “Overuse of Health Care Services in the United States,” by Deborah Korenstein, MD, Ralphael Falk, MD, MPH, Elizabeth A. Howell, MD, MPP, Tara Bishop, MD, MPH, and Salomeh Keyhani, MD,  published in Archives of Internal Medicine. The committee cited this article as an “excellent contribution to the field and state of knowledge about overuse” through its thorough review of overuse research to date and recommendations for further areas of study. Overuse relates to the Physician Charter principle of the primacy of patient welfare and the commitments of improving quality of care and just distribution of finite resources. 

We welcome your reactions to the Professionalism Article Prize winners. Please share your thoughts, including your favorite professionalism articles from 2012, below.

• The authors of “Five Years’ Time and The Next Five Things for the List of Choosing Wisely” reflect on the evolution of hospice and palliative medicine and discuss research needed to develop another five items for physicians and patients to question.
• A new article in the Journal of the American College of Radiology suggests ways to modify the curriculum and assessment tools for radiology residents to place a greater emphasis on professionalism.
• The authors of a literature review on professionalism in surgical education provide recommendations for developing an effective surgical professionalism curriculum.

During her stay in the hospital after her stroke, we were confronted by the decision whether or not my mother-in-law should have her pacemaker changed. It was up for replacement and her cardiologist felt it would be convenient to have it done while she was in the hospital, and thought she would suffer from heart arrhythmia if she didn’t have it replaced. They did the procedure and afterwards she had considerable post-surgical pain and discomfort. Given her fragile state, it now seems like an unnecessary procedure but at that moment, to the family who was only concerned about her comfort level and restoring her back to health, it seemed like the logical decision to go through with it.

After two weeks, my dear mother-in-law was transferred to a rehabilitation facility with the hope for a return home to her daughter’s house where she lived prior to the stroke. Her rehabilitation potential was poor. Her condition worsened, probably due to more strokes. Her creatinine levels were sky high, her organs were starting to fail and it soon became obvious that her last days were imminent. Hospice was finally called in and a consult was given, as is the case too many times—too late to make a difference. Her close-knit family gathered around her bedside to be with their mother. The next day her pain started. Her organs were failing and she began to cry out, howling with pain. The day before, her physician had ordered painkillers and morphine to be given as needed, but the nurse on duty reported they were out of the painkiller. It struck me as very poor execution of a care plan – a painkiller is ordered and less than 24 hours later, they run out? Once the morphine was given, her horrifying screams subsided but her family felt guilt-ridden about their mother’s pain. It was the thing they most wanted to avoid if at all possible and it had been possible with a quick inventory check.

My wife and I were present for her last breath.

The family gathered as the mortician, with amazing dignity and respect, lifted her gently out of the bed. I realized how he and the funeral home were all part of the care and healing process.

It was a good death but it could have been better, with more appropriate care given at critical times. It made me think of Choosing Wisely® and how good quality health care is not just about avoiding unnecessary care. It’s about getting the right care, the most appropriate care, at the right time.

• The American Medical Student Association has released its 2013 PharmFree Scorecard, which issues letter grades to medical schools based on their conflict of interest policies. A Community Catalyst blog post provides highlights from this year’s PharmFree Scorecard and reactions from several medical school leaders.
• Researchers developed a Handoff Clinical Evaluation Exercise (CEX) to assess the quality of handoffs of patient care from one physician to another, which included an assessment of the transferring physician’s professionalism. They found that the tool performed similarly in two institutions, although peer evaluators consistently gave one another higher marks than external evaluators.
• The authors of a new JAMA commentary argue that physicians can use “evidence-based persuasion” with patients while still respecting patient autonomy and provide advice on how physicians can balance persuasion and patient autonomy.

It seems like every day:

• another clinical journal comes out citing Choosing Wisely and its goals (there have been 103 journal articles published to date);
• a health system is interested in joining our learning network;
• a minister of health from an international country calls us wanting to understand the campaign’s dynamics; or
• a thoughtful opinion piece  points to how the campaign has legitimized and given permission to physicians to discuss overuse with their patients.

In the past year, the campaign has shined a light on:

1)      The lack of medical evidence. The clinical evidence available was the basis for the Choosing Wisely recommendations. We know from previous research though that not all of the sound evidence is followed in practice. However, many specialty societies struggled with the lack of scientific data to support what to do and what not to do. Most clinical evidence supported the “do’s” but not the “don’ts.” A recent examination of cardiovascular clinical practice guidelines found that only 11 percent were supported by the highest level of evidence (from systematic reviews and meta-analyses). Additionally, a recent review of the National Cardiovascular Data Registry-ICD Registry found that 22.5 percent of patients received non-evidence-based implantable cardioverter-defibrillators. There are scant studies that include costs with the evidence analysis. PCORI and AHRQ can add to the evidence but are prohibited legislatively to add cost into the equation.

2)       The lack of physician knowledge, skills and attitudes (KSA) in resource use. The ABIM Foundation is exploring the state of medical education and training as it pertains to teaching about resource use. It appears to be a negligent area in medical education and insufficient in continuing medical education. Costs of Care and the ABIM Foundation are conducting a competition to uncover some “bright spots” (promising and best practices) in the area of curriculum and experiential learning. ACGME Milestones for Internal Medicine now has a competence focused on resource use. Steve Weinberger, MD, EVP and President of American College of Physicians (ACP), has written about making high value cost conscious care the seven competency of ACGME/ABMS. ACP has developed excellent curriculum for residents. The tide is turning but it will take some time to go from volume-based culture where the question is “Why didn’t you order that test?” to a value culture where the question is “Why did you order that test?”

3)      The gap between health systems interested in removing waste and providing the most appropriate care and their ability to do so.  There is a new chasm between the number of health systems wanting to achieve the highest value and remove waste from their systems, and the lack of infrastructure (information systems and organizational structures), cultural readiness, KSA and aligned incentives to support this goal. Policy makers believe that the prerequisites to move away from fee-for-service will instantly cause practice changes. Administrators have been trained to maximize revenue through better coding not by improving health, quality of care and affordability for the population. Patients still believe more is better and physicians are unable to manage uncertainty in medicine and will do the extra tests without the science to make them up just to be 100% certain. (Which is why I received two EKGs preoperatively for two detached retinas.)

So where does this leave us? Perhaps by shining light on these shortcomings that prevent the removal of waste in the system, we’ll create the will and urgency to improve evidence, and improve the competencies of physicians and health systems in order to remove the estimate $210 billion of waste in health care. I look forward to the year ahead.

In memory of Richie Havens (1941 – 2013):

• Johns Hopkins researchers conducted a randomized-controlled trial to determine whether presenting cost data to providers when they ordered a test affected test ordering. They found that presenting this data to providers resulted in a modest decrease in test ordering.
• In a recent Teaching and Learning in Medicine article (pdf), the authors presented internal medicine residents with vignettes illustrating common stewardship challenges, such as patient requests for brand-name medications or deciding whether to repeat an imaging test conducted at another facility. They found that the residents had inconsistent responses to the vignettes.
• The American College of Physicians and the Federation of State Medical Boards issued a policy statement on online professionalism and physician-patient relationships. Among their recommendations, they advise that physicians behave professionally in both personal and professional social media communication, and “should not ‘friend’ or contact patients through personal social media.” 

Dr. Erb recently shared his thoughts on the Choosing Wisely^® campaign:

What was your initial reaction to the campaign?

When I first heard about it, it took a little while to sink in. Politically, there could be a negative response to the campaign because the real conundrum is that we live in a world where physicians are being asked to limit the care they provide in what remains a volume-driven system.

What affect did Choosing Wisely have in your practice?

When Choosing Wisely came out, it simplified my approach in telling folks they don’t need certain things. Before, all I could do was refer patients to our practice guidelines, and those are really unwieldy for a lay population. Referring physicians weren’t reading them either.

Choosing Wisely distilled the guidelines and made them easy to read. Just look up the Choosing Wisely website – it’s all based on data and evidence.

It’s really made the conversations much easier with patients, and referring physicians. When a patient asks for something they don’t need, I can say to them “In keeping with the Choosing Wisely campaign, we will not perform cardiac stress testing.”

I also make sure to cite the Choosing Wisely guidelines in my dictation to referring physicians.

How do your patients react when you tell them they don’t need a test or procedure?

The success of those conversations depends on how you couch them. If I tell them they don’t need something and there’s no evidence it will help them, 99% of patients accept it with no questions asked. They say, “If I don’t need it, I don’t want it.”

But there are still some patients that will say they want it, even if I tell them it provides nothing but false security. But I think that will be a small number of patients.

I’ve been promoting Choosing Wisely for about six to eight months. So far I’ve received no push back from referring doctors, and maybe two patients. It’s just a matter of honest conversation.

Do you think the campaign has been successful so far? Why?

An important part of the campaign is it started the conversation. It’s actually succeeded in starting the conversation at a grass roots level where others have failed. Part of it has to do with the multi-specialty buy-in. It’s not from one set of doctors, or health care stakeholders – it’s from the physicians themselves. That makes it difficult to ignore.

What challenges does the campaign face in meeting its goals?

The number one issue is payment—we have a volume-driven system. Physician reimbursement has been slashed to where it’s difficult to meet overhead. Without addressing that, it’s going to be tough gaining traction with the campaign. The next step is to go to payers and say, ‘The ball is in your court.’

It’s also well noted by the Dartmouth Atlas that different areas in the country develop their own medical ecologies. There are some areas where some tests—like coronary stress tests—aren’t performed regularly, but some areas where they are. There’s huge variability in health care consumption in this country, and it’s a reflection on these medical ecologies. Campaigns like Choosing Wisely have the potential to start leveling out that variation.

How can the campaign continue to grow and make an impact?

What we need to do is continue to push through the specialty societies. They’re going to respond to their own kind. I think continuing to work aggressively with the specialty societies will be critical to success. To get specialty societies involved is a huge step and has given a lot of credence to the campaign.

 But at some point you need to ask – what’s the end game? What are we really looking for? I think we’re looking for a way to shift from volume to value. Choosing Wisely may be in a position to do that. You could go to payers and say, you need to work with us if we’re going to affect this change.