Bioethics Forum Essay
Two Cheers for Choosing Wisely
The Choosing Wisely campaign is one of the most exciting experiments in health care in quite a while. If it lives up to its potential, Choosing Wisely could prevent some of the harm caused by unnecessary tests and treatments, while helping to bring down medical costs. But the real challenge to the campaign is whether it actually “empowers” consumers to do anything other than hurl themselves at a brick wall.
Choosing Wisely, begun in 2012, challenges medical specialties to create lists of the five most commonly misused and overprescribed interventions. Today there are more than 50 lists. Consumers Union is helping the campaign to bring its message to consumers in user-friendly form. And, indeed, the campaign is doing a wonderful job. The website (choosingwisely.org) has not only the lists, but terrific back-up resources to help laypeople understand the reasoning behind the lists. There are explanations about everything from why to avoid feeding tubes for Alzheimer’s patients, to how often one needs a colonoscopy.
True, Choosing Wisely is a work in progress. I wish dentists and orthodontists would sign on. And the current lists have been criticized for focusing on low-ticket items or on interventions performed by other specialties. Number one on the list from the American Academy of Ophthalmology, for example, is routine electrocardiograms (EKGs) before cataract surgery, a relatively low cost intervention provided commonly by primary care physicians.
The rationale for the campaign is to “educate and empower” consumers (whom they insist on calling “patients”) and to “promote conversations between providers and patients.” The goal is to help consumers choose care that is evidence-based and not harmful. As a bioethicist, occasional “patient,” and full-time autonomy freak, I could not have been more excited, until I actually tried to put Choosing Wisely to use.
Last fall, I decided to have cataract surgery, to remedy my increasingly impaired night driving. Because of an underlying condition in the relevant eye, I needed to see a specialist surgeon. My appointment with him was extremely thorough, and it included a clear explanation of the procedure, the risks and the benefits, and adequate time for questions. After two hours of tests, I was decanted into the office of the scheduler, and she gave me an appointment for surgery three months later. She also told me to make an appointment with my primary care physician for an EKG.
The next day, while showing the Choosing Wisely website to my son, I realized that I should have questioned the need for the EKG. But when I tried to call the surgeon to discuss the matter, to have the “conversation” Choosing Wisely was founded to support, I was stymied at every turn. No one at his office would allow me to speak with him when they found out what I was calling about; EKG’s were “routine,” and therefore it was pointless for me to discuss it. I enlisted my primary care physician, a wonderful woman committed to evidence-based medicine. She agreed that the EKG was not warranted and she tried to call the surgeon herself; to my astonishment, she was also stonewalled. At the same time this was happening, the American Academy of Ophthalmology’s website featured this very issue, front and center, emphasizing that routine EKG’s are not recommended. “[The American Academy of Ophthalmology urge[s] you to have a conversation with your ophthalmologist to discuss if preoperative tests are important for you based on your particular history and physical examination,” chirps the website, but how can I have a conversation if the guy doesn’t even know I am trying to call?
Eventually, I resorted to snail mail, marking the envelope “personal,” and including printouts of the American Academy of Ophthalmology’s website and the articles on which the recommendation was based. I got back a nice phone message from the surgeon agreeing with my concern, but regretting that the surgery center he uses would not allow him to operate without the EKG. The surgeon blamed the anesthetists; my primary care doc, now on a mission, called them as well, but got nowhere.
By now, almost two months had gone by. Should I jettison the time and money I had already spent with this surgeon and start all over again, finding a different surgeon in a different city, who would doubtless be “out of network” and thus cost even more? Or should I subject myself to an unnecessary EKG, courting the possibility of a medical cascade that could lead to risky, unnecessary, invasive procedures? In the end, I showed up at my primary care doc’s office and we ruefully went through the charade of the EKG (which, of course, my insurance company happily paid for).
So where did Choosing Wisely get me? I ended up feeling adversarial and angry with someone who was about to put sharp objects in my eye. Not a helpful outcome. To rub salt in the wound, there is a slightly condescending air to much of the rhetoric surrounding Choosing Wisely, as if it is we poor, misguided, anxious patients who are pressuring doctors for unnecessary procedures. “If patients are worried that they have heart disease and haven’t gotten a recent EKG, part of it is explaining to patients why more is not always better,” Dr. [Lee A.] Fleisher said, in an article in Eyeworld on exactly this issue. How about explaining that to physicians?
The Choosing Wisely website is full of cool resources for physicians, including handouts for patients and communication modules that help physicians implement Choosing Wisely principles with patients. Now how about some modules to support patients in talking with their physicians? Or just getting their physicians to pick up the phone?
Dena S. Davis, JD., PhD, is the Presidential Endowed Chair in Health and a professor of religion studies at Lehigh University. A version of this essay originally appeared on her blog, Bioethics and Other Stuff.
Posted by Susan Gilbert at 12/18/2014 02:02:03 PM |