At the meeting, a high-level physician executive of one of the largest health care plans with multiple diversified products addressed an audience of 350 employers who purchase health insurance for their employees. He spoke about information they currently collect on physician quality and cost performance, and described their ability to segment physicians into four quadrants of quality and costs with high quality and low cost being the sweet spot. This kind of segmentation would enable their subscribers to select the best physicians and hospitals. Claims data could provide that and more. Health plans claim they can compile such meaningful data from multiple sources – both inpatient and outpatient care – and integrate those data sources to provide a total picture of health care received.

Frankly, it all sounded pretty good – what he was describing was a virtual, integrated system of care with a health information exchange among the vast spectrum of care settings.

But I couldn’t get past his use of the metaphor of a train leaving the station. Far too often I’ve seen this kind of rhetoric of “get aboard now or we’ll leave you behind” instill fear into the hearts and minds of those who don’t believe in the large health plan’s construct of quality and cost. While I, too, am impatient with the pace of change of the U.S. health care system, I’m wary of the implications to the Choosing Wisely campaign if we rush to evaluate its impact:

• Health plans and quality assessment organizations will rush to measure the Choosing Wisely recommendations before the practices can learn about what is required to bring about these complex changes in practice. Accountability works best when there is agreement among all stakeholders (physicians, patients and purchasers) upon what should be improved and how is this important to better health care.
• There will be a lack of understanding of the importance of attitudinal and cultural changes by physicians and clinicians in solving the economic sustainability of the health care system. Without attitudinal change behavior change, practices will resist the desirable changes.
• Are the health plans the right messenger? Trust in the supplier of the data and the recommendations does matter.
• We can’t leave out the physicians, clinicians and patients. If they are left behind at the station, we will never get this right – the right care, for the right patients and in the right setting.

The initial aim of the Choosing Wisely campaign was to increase the awareness on the issue of overuse. Having the specialty societies taking a leadership role in identifying unnecessary care along with the support of Consumer Reports drew an enormous amount of attention by the media and the medical and patient community. A more rational conversation has occurred. Health insurance companies like the one that presented at this conference have not been able to build trusting relationships among patients and physicians to have these conversations.

So this brings me back to the question of the campaign’s overall value if the train leaves the station without the patients and physicians aboard.

• In “From an Ethics of Rationing to an Ethics of Waste Avoidance,” Howard Brody argues for a stepwise strategy to eliminate unnecessary care given the limitations of comparative-effectiveness research, saying, “it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit.”
• M. Gregg Bloche urges policymakers to move beyond the elimination of unnecessary care, stating that “eliminating only ineffective care would shift the cost curve down but wouldn’t change its slope.”
• A new Academic Medicine article identifies fairness as a guiding principle for professional behavior, and suggests organizational professionalism includes the ethical stewardship of resources.

In case you missed it, a recommendation came out last month that physicians cut back on using 45 common tests and treatments. In addition, patients were advised to question doctors who recommend such things as antibiotics for mild sinusitis, CT scans for an uncomplicated headache or a repeat colonoscopy within 10 years of a normal exam.

The general idea wasn’t all that new — my colleagues and I have been questioning many of the same tests and treatments for years. What was different this time was the source of the recommendations. They came from the heart of the medical profession: the specialty societies representing cardiologists, radiologists, gastroenterologists and other doctors. In other words, they came from the very groups that stand to benefit from doing more, not less.

Nine specialty societies contributed five recommendations each to the list (others are expected to contribute in the future). The recommendations each started with the word “don’t” — as in “don’t perform,” “don’t order,” “don’t recommend.”

Could American medicine be changing?

For years, medical organizations have been developing recommendations and guidelines focused on things doctors should do. The specialty societies have been focused on protecting the financial interests of their most profligate members and have been reluctant to acknowledge the problem of overuse. Maybe they are now owning up to the problem.

And judging from the content of the list, testing is a big part of that problem. Only a quarter of the recommendations fell in the category of “don’t treat” — as in, don’t prescribe more chemotherapy for end-stage cancer that is beyond hope. The remainder fell in the category of “don’t test.”

Because it can be the first step in a cascade of medical interventions, the focus on testing makes good sense. The specialty societies seem to now recognize that the results of testing include both signals (useful information) and noise (false and distracting information). For patients with symptoms the signal predominates. But for those without symptoms the noise predominates. And the noise is not harmless, it can trigger overdiagnosis and overtreatment. “Routine” chest X-rays, for example, have a way of unearthing multiple abnormalities. This raises questions in physicians’ minds — triggering CT scans, needle biopsies, bronchoscopies and even surgery in an effort to answer them.

That’s why multiple recommendations have argued against routine use of tests such as cardiograms (EKGs), ECHO and CT scans in asymptomatic patients — and against repetitive testing in patients whose symptoms have not changed.

Admittedly, some of the recommendations seem brain-dead obvious.

• Don’t screen for cancer in dying patients. (How could they possibly benefit from the early detection of a cancer that will not have time to progress?)
• Don’t screen for cervical cancer in women who don’t have a cervix. (How could they possibly be at risk for cancer in an organ they no longer have?)

You might think such guidance would be unneeded. Sadly, research using the Medicare data has demonstrated both those things regularly occur.

Other recommendations have been around for years:

• Don’t order CT scans and MRIs on patients with nonspecific low back pain.
• Don’t order routine preoperative chest X-rays.

Yet those orders continue.

Most doctors will agree with the recommendations on the list. But the problem of overuse is less one of bad doctors (although there are a few); the problem is more one of good doctors working in a bad system.

The truth is there are many forces that push us to do more. There are the performance measures that typically give doctors good grades for ordering tests, rather than for not ordering them. There is the legal system that will punish us for underdiagnosis, but not for overdiagnosis. There are the demands from patients seeking to get their money’s worth from insurance after years of being taught to believe the best medical care is the most medical care. And there are the financial rewards: Most doctors, and/or the clinics and hospitals they work for, are paid more if they do more.

But we have to start somewhere — and this list is a good start. Now it needs to be extended.

Personally, I would have liked to see the recommendation: “Don’t perform breast or prostate cancer screening unless the patient understands both the harms and benefits.” Or perhaps we could think even more broadly: “Don’t feel compelled to end every patient encounter with an order for a test, a recommendation for a procedure or a prescription for a medication.”

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. He is the co-author of Overdiagnosed: Making People Sick in the Pursuit of Health<

• Brad Flansbaum asks whether we are “Choosing Wisely or Vicely” on the Hospitalist Leader blog.
• The Wall Street Journal calls Choosing Wisely “Care That’s Just Right”
• American Cancer Society Medical Director Otis Brawley delivered a speech at a recent Association of Health Care Journalists meeting in Atlanta, in which he argued that we are all responsible for overuse.

“Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the U.S. health care system, but without it, the health care enterprise is lost.”

 I find myself drawn time and again to this prescient quote from an important and timely JAMA article by Cara Lesser, Catherine Lucey and colleagues. There has never been a time in our history so desperate for medical leadership and rampant professionalism. When the article was first published, I sent the PDF to all of my faculty colleagues at Penn State College of Medicine; it received more positive comments than anything else shared from my office over the past decade. I got the sense that most people felt as I did: While we all considered ourselves professional and sincerely desired to be stellar role models to our students and residents, we would be hard-pressed to list five random acts of professionalism committed in a given week. Rarely did we spontaneously celebrate such acts when witnessed.

When Secretary of Health and Human Services Kathleen Sebelius and Attorney General Eric Holder toured the county last year speaking out against fraud and abuse in government health care programs, Ms. Lesser graciously agreed to allow me to use concepts from the article in my comments as a panelist for the Philadelphia conversation. The gist of what I shared was that, although most physicians are well-intentioned and honorable, the convoluted, complex and often indecipherable rules by which we must meet the needs of our patients and justify compensation for our services “aids and abets true criminals and tortures the rest of us.” We simply want to do what is right by our patients and have that be the path of least resistance in our harried and hectic professional lives.

The literature on medical professionalism is as old as… well, the profession itself. Professionalism is derived from the Latin, professio, to declare publicly. Formal definitions of professionalism, while lofty and generally noncontroversial regarding what we should profess – integrity, altruism, compassion, self-regulation – tend toward the abstract. They have always left me asking for more substantive and actionable examples. Lesser and Lucey provide this. Their message is that professionalism can and must be translated into action, both for individuals and institutions. They provide concrete, actionable and most important, teachable examples. I was attempting to do the same in a recent whimsical, but sincere, post on parsimonious care.

With the recent announcement from the Accreditation Council for Graduate Medical Education (ACGME) of the Next Accreditation System (NAS) for residency programs, we may be at a tipping point. To maintain accreditation, residency training programs will need to translate the core competencies into general and discipline-specific observable behaviors. For example, with respect to professionalism, how did a resident “develop and apply a consistent and appropriate approach to evaluating care, possible barriers and strategies to intervene that consistently prioritizes the patient’s best interest in all relationships and situations?” Rather than simply feeling empathetic toward the poor soul whose diabetes is out of control for lack of money and/or stability in his life, the “professional in action” lines up social services and a care coordinator to help out.

Choosing Wisely provides us with numerous additional examples of how we can translate the abstraction of professionalism into observable, measurable and teachable moments. The ABIM Foundation, collaborating specialty societies and numerous other supporters should be commended for this campaign. Kudos also to the ACP and Consumer Reports on their efforts to educate our patients regarding “high-value care.” There should be very few “aha moments” for well-informed and up-to-date physicians in these recommendations. However, they provide numerous and very specific scenarios where we can educate our patients, students and the general public about the tremendous waste and potential harm perpetrated by old habits, outmoded thinking and misaligned financial incentives.

We may someday be forced to ration high-value health care services in the U.S. by some mechanism other than lack of insurance coverage. We can postpone that day of reckoning by providing, teaching and rewarding more rational practices and making our random acts of medical professionalism a way of life.

Michael Weitekamp, MD, MHA, FACP is a Professor of Medicine at Penn State College of Medicine and a Robert G. Petersdorf Scholar at the Association of American Medical Colleges. He blogs at Wing of Zock, and can be reached at mweitekamp@aamc.org.

What is powerful about the Choosing Wisely campaign and other similar efforts (e.g., American College of Physicians,  the National Physicians Alliance and the Archives of Internal Medicine) is what can happen when physicians are empowered to provide leadership and speak out about important issues such as appropriateness and waste. The potential attitudinal and cultural changes about waste and overtreatment can, as Don Berwick said, be a “game changer.”  Driving forces behind high-performing delivery systems have been leadership, culture and values; all of which lie at the core of the Choosing Wisely campaign.

Delivery systems are now beginning to think about how to implement the recommendations of the societies. There is complexity in implementing any intervention that results in changes in clinical practice. In addition, there is complexity in measuring changes in utilization – the societies’ recommendations are not absolutes. There are lots of exceptions based on individual patient history and preferences. Understanding these complexities of implementation will take time, but it is a necessary step to avoid a rush to evaluation and accountability.

As Don Berwick stated, “Payers, even while they celebrate the step of professional leadership, should exercise restraint in converting these lists into hard-wired payment rules.”

The ABIM Foundation is in this for the long run and we look forward to watching this campaign grow and mature. Already 10 more specialty societies have joined the original nine specialty societies (and others are considering it). Consumer Reports will be creating and distributing patient-focused explanations of the specialty society recommendations. This is proving to be a viral campaign – many conversations are occurring among physicians and patients without government and payer interventions. Lots of organizations are thinking about implementing strategies.

The time has come to give this kind of professionalism a chance.

• The Commonwealth Fund Commission on a High Performance Health System issued a proposed strategic plan for community-based approaches to improving care and lowering cost for individuals with chronic illnesses. They estimate that creating 50 to 100 voluntary “Health Improvement Communities” could result in $184 billion in health care savings over a ten-year period.

• The Patient-Centered Outcomes Research Institute outlined its vision for patient-centered comparative effectiveness research in a new issue of JAMA.

• Right messenger
• Right message
• Simple actionable steps
• Respectful and trusting relationships

In this post, I want to address the last, fourth pillar for the campaign: Respectful and trusting relationships. It is these relationships that will ultimately determine the success of the Choosing Wisely campaign. These respectful relationships are not just patient/provider, but physician/physician, society/member, government/stakeholder and beyond.

• When clinicians work together in high functioning teams with mutual respect and trust, patients benefit.
• Quality and costs are dramatically improved when payers, purchasers and the government respect and collaborate with physicians and providers by changing financial incentives to align with redesigned health care delivery systems (e.g., medical homes and accountable care organizations).
• Patty Gabow, CEO of Denver Health, at her acceptance speech for NCQA’s Quality Award, spoke about the importance of respect in removing waste from the health care system through “lean thinking”. “Waste is disrespectful to [physicians] by asking them to do work with no value and … waste is disrespectful to our patients because it asks them to endure processes with no value and reduces the quality of their care.”
• When the specialty societies involved in the Choosing Wisely campaign announced the five tests and procedures to question, they did it with much respect for their patients and society members.  The specialty societies reached out to their members in a respectful way to explain why they chose those five tests and procedures. After the lists were published, we have heard of many thoughtful conversations where physicians have discussed the merits of these recommendations.

Through the campaign, we hope to change the tenor and nature of the conversation about waste and unnecessary care that adds no value to patients and is costly to communities and the nation. These conversations can only be productive when all stakeholders come together with respect for the same goal and for each other.

• Forbes notes that Choosing Wisely “has dominated health headlines since nine medical specialty boards recently announced their support…”
• David Katz, Director of the Yale Prevention Research Center, calls Choosing Wisely Good Answers for Good Questions.
• Michael Barry of the Informed Medical Decisions Foundation developed a brief video giving an overview of the campaign and key takeaways.
• Robert Centor of db’s Medical Rants rebuts pushback against the campaign.

Choosing Wisely is a campaign that we hope inspires others to join in the conversation about  these, and other tests and procedures that may be unnecessary. We hope to hear from members from the following groups:

Practicing Physicians: The next time one of the tests or procedures from one of the“Five Things” lists is requested from a patient or caregiver, talk with your patient about the specialty society’s recommendations. If you practice in a group, speak with the other physicians about these recommendations and how you want to handle them in your practice. How important to your practice is it to eliminate care you are currently providing? Is this care part of the economics of your practice? Are there other tests or procedures that should be talked about?

Patients: When a physician recommends a test and procedure on these lists, or that you think you might not need,  talk to your doctor about the benefits to you and your health. Will it help make a diagnosis? Will it ultimately restore your health or relieve pain?

Medical Leaders from Health Systems and Hospitals: Examine the lists and begin discussions about whether some of the tests normally conducted should be revisited.  What are the exceptions to these recommendations and how should they be handled?  How are you going to involve your admitting physicians, hospitalists and patients in these discussions? How can you recognize appropriate use of resources? How would your business model need to change?

Medical schools and residency programs: Choosing Wisely is potentially a learning opportunity for medical students and residents. Learning how to read evidence-based studies and think about probabilistic theory is a competency needed by learners and faculty. Might medical schools and residency programs develop their own lists of five tests and procedures as a way of thinking about decision-making and utilization of services?

All stakeholders in our health care system have a role to play in Choosing Wisely. Please share your thoughts, ideas, and stories of success so we can learn from one another and make better decisions about our health care.