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The Medical Professionalism Blog

The Language of Choosing Wisely

In my last post about the 2012 ABIM Foundation Forum, I wrote about physician and patient competencies needed in the 21st century to achieve the triple aim (improving the patient experience, improved health of populations, and reduced per capita cost of health care). I was inspired by the thoughtful conversations that took place at the Forum exploring ways to improve our health care system, and I believe it’s these rich conversations that lead to changes in hearts and minds, and ultimately to actions and results.

In one of the Forum sessions, participants organized in small groups to develop approaches and messages about how they would talk with their respective constituencies—patients, physicians, policymakers, payers, purchasers and researchers—about appropriateness of care and reducing waste.

Language is important. In previous blog posts, I wrote about the issue of language and messages. I thought I would share with you some the words of the Forum participants. I think their ideas, advice and comments highlight how we as a community need to frame the issue of overuse and waste:

  • Physicians should try to discover patients’ true preferences and desired outcomes when discussing what tests and procedures they need.
  • Be careful placing too much emphasis on harm from tests and procedures.
  • We need more patient stories of high-quality, coordinated care with appropriate services being delivered.
  • Stories should also come from care teams, including the physicians, showing examples where good quality can cost less and that high cost doesn’t necessarily mean high quality. One participant noted that, “The secret in the care of the patient is in truly caring for the patient.” They further explained that this includes, “Do no financial harm.”
  • There are often uncertainties in medicine and patients need to understand this through discussion with their health care team.
  • Create a drum beat of persistent messaging with positive language.
  • The rationing argument does not apply. Rationing is about denying care to those who need it. But efforts such as Choosing Wisely are about providing exactly the care that is needed.
  • “More care does not always equal better care.”

What impresses me most about these comments is the positive framing of appropriateness—getting all the care that is needed through systems designed to address the needs of patients and families. Appropriateness and waste are not seen just as a physician not ordering tests, but as patients and physicians coming to a collective understanding of the reasons for and against using a specific test.

I am hopeful we can build on the positive thinking of Forum participants as we seek ways to address the challenges facing our health care system. With the latest estimates from the IOM that up to 30% of all health care spending is wasteful, thoughtful conversations between physicians, patients and other health care stakeholders will be needed to reduce unnecessary care and improve the system for all.

3 Comments to The Language of Choosing Wisely

  • Ronni Sandroff's Gravatar Ronni Sandroff
    September 20, 2012 at 3:48 pm | Permalink

    Daniel, this is such an important point: “The rationing argument does not apply. Rationing is about denying care to those who need it. But efforts such as Choosing Wisely are about providing exactly the care that is needed.”

    Just returned from focus groups in the heartland and the ‘death panel’ myth lives on. I very much like the way you’ve framed it here.

    As a Consumer Reports editor I’m not sure I agree about not emphasizing harm done from tests and procedures, however. That’s the very thing that will make consumers wary of unnecessary treatments.

  • Daniel Wolfson's Gravatar Daniel Wolfson
    September 21, 2012 at 9:26 am | Permalink

    Thanks Ronni for your comment. I agree that the potential harm of tests and procedures can be a very a potent message, and one that’s important for patients to think about. The danger of placing too much emphasis on “harm” is that people could become afraid of getting tests that are actually beneficial to them. Through Choosing Wisely we’re trying to encourage patients and physicians to have conversations about what tests and procedures they will benefit most from, while avoiding those that are unnecessary or could be harmful.

  • Lyn Paget's Gravatar Lyn Paget
    September 27, 2012 at 2:17 pm | Permalink

    Great blog, Daniel.

    Might there also be a value added benefit here of creating a genuine partnership between patient and clinician around evidence? We know this is something that patients strongly desire, clinicians need to be receptive of, and the campaign inspires.

    What we need is experience on both sides of the communication equation to bring us to a place where experience fuels engagement and understanding.

    Some new data has been released in an IOM discussion paper that sheds more light on the priorities of patients: http://www.iom.edu/Global/Perspectives/2012/Evidence.aspx

    This all points in the same direction and the action orientation of Choosing Wisely is a model to be applauded.

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