Commonly used tests and procedures are often the ones that physicians and patients don’t question. But some of these tests aren’t necessary, and others even cause harm. In delivering health care today, physicians and patients alike must think about the relative risks and benefits of each test or procedure, no matter how common it is, in the context of the evidence that supports it and the resources it demands.
The Choosing Wisely campaign, initiated in 2012 by the American Board of Internal Medicine, aims to get physicians and their patients thinking critically about the overall value of common medical tests and procedures. The campaign is sparking thoughtful discussion across the United States.
At NEJM Knowledge+, we were curious to learn what effect the Choosing Wisely campaign is having specifically on the front lines of the practice of family medicine. We started with the fact that, prompted by the Choosing Wisely campaign, the American Academy of Family Physicians (AAFP) has selected “15 things that physicians and patients should question” in family medicine. We wondered which of the 15 AAFP-identified recommendations are proving to be the easiest to follow and which seem to be the toughest to implement on the front lines of care.
So we approached three family physicians for their perspectives on this issue. We didn’t have them reflect on each and every AAFP recommendation (you can peruse the complete list here). We simply asked them to highlight the ones that, in their daily practice, stand out as particularly worthy of discussion — and to discuss the importance of the Choosing Wisely campaign more broadly.
Why Choosing Wisely Matters
Caroline Richardson, a family physician and research scientist with the VA Health System in Ann Arbor, Michigan, thinks that awareness of most Choosing Wisely recommendations has been high for some time. The great benefit, she believes, is the campaign’s recent success “as a marketing tool.” She puts it this way: “Choosing Wisely cleverly frames its recommendations as good, evidence-based medicine rather than as denying care to patients. In that way, it has helped physicians and patients buy in to the concept that ‘less is more.'”
Does that mean that all 15 of the AAFP-designated Choosing Wisely recommendations are being implemented seamlessly? Of course not. Richardson points out that even some of the recommendations that have long been widely accepted — such as those about overuse of antibiotics for otitis media in children (#11 on the AAFP list) and for mild-to-moderate sinusitis in the overall population (#2) — are still tough to execute. “When you have a patient or a parent standing in front of you asking for treatment for obvious discomfort,” she notes, “sometimes we’re still bad at saying no.” But Richardson believes that since the Choosing Wisely campaign was launched, a politely and clearly explained “no” response in such circumstances is becoming more palatable to both physicians and their patients.
Richardson notes that certain Choosing Wisely recommendations — such as not performing Pap smears in women younger than age 21 (#5), not screening women younger than age 30 for cervical cancer with HPV testing (#10), and not doing a pelvic exam before prescribing an oral contraceptive medication (#15) — are much easier to implement. “After all,” she says, “most women are not seeking out opportunities to get a pelvic exam.” However, in the case of the HPV guidelines, the directives are relatively new. “So it’s more a question,” Richardson notes, “of how familiar the physician is with the specifics of the recommendation. Choosing Wisely has helped providers recognize the importance of knowing the guideline particulars — and then caring for patients accordingly.”
From Richardson’s perspective at the VA, organizations that emphasize systems-level thinking about the delivery of care have, as she puts it, “really taken up the banner” of implementing Choosing Wisely’s goals, bolstered by the ongoing efforts of medical professional societies. And she believes that physicians in academic medicine also play a vital role as more comparative-effectiveness research is conducted and as care-delivery tools, such as up-to-date electronic medical record (EMR) prompts and report-card feedback for physicians, are developed and tested. “If, for example, a doctor receives feedback saying that he or she imaged 50 of the most recent 100 patients with new-onset low-back pain,” Richardson says, “that physician will think twice about ordering a scan the next time.”
Choosing Wisely in the Trenches of Clinical Practice
Michael Lokale, a family physician with Northwest Allied Physicians in Tucson, Arizona, offers a practical perspective from the front lines of patient care. He sees, on average, roughly 110 to 120 patients per week; about 65% to 70% of them are adults younger than age 65.
For Dr. Lokale, Choosing Wisely provides a useful distillation of important guideline recommendations that are relevant to his family medicine practice. “Choosing Wisely puts much of the guideline advice in one convenient place,” he says. “There are many guidelines, so it’s a matter of simplicity.”
Choosing Wisely also helps Lokale articulate an evidence-based rationale to his patients. He says, “I lean on Choosing Wisely a lot when I have to tell patients why I’m opting not to do something or why I’m following a certain treatment plan.” He has found it especially useful in explaining why he does not do routine prostate-specific antigen (PSA) testing or a digital rectal exam (DRE) to screen men for prostate cancer (recommendation #13). “I say, ‘I will do a DRE if you really want it, but the evidence is against it.'” Of course, most men don’t really want a DRE, so this lighthearted exchange with Dr. Lokale is helpful in gaining acceptance from the patient.
Like Dr. Richardson, Dr. Lokale finds the recommendation not to overuse antibiotics (recommendations #2 and #11, cited earlier) to be the most challenging to implement. He says that many patients are still unaware of the potential harm from antibiotic overuse.
He shares an anecdote in which a 59-year-old woman presented to his practice with a cough. She had previously been through three rounds of antibiotics for abdominal illness and had even been diagnosed with Clostridium difficile infection, which had eventually resolved. Yet she was not aware that going on another antibiotic for her cough (which might have been viral in origin anyway) would put her at risk for a C. difficile recurrence. “That suggests to me that patients’ awareness of the Choosing Wisely recommendations is still low,” he says. “Most doctors are familiar with the recommendations, but in reality, sometimes the guidelines are not followed because the patient wants treatment.” When Lokale explained to the patient that taking another antibiotic would raise her risk for C. difficile, she readily followed his advice.
Dr. Lokale says that he also finds it challenging to implement the recommendation not to screen adolescents for scoliosis (#14). He indicates that many parents still believe that because they had a thorough scoliosis check when they were teenagers, their children should as well. “So that can be a tough one,” he says, “but still not as tough as the recommendations about antibiotics.”
Lokale believes that attending annual AAFP meetings, where there are always talks that highlight Choosing Wisely, is a great way for keeping clinicians and, by extension, their patients up-to-date on avoiding unnecessary and potentially harmful tests and procedures. He makes sure he goes every year.
The Implications of Choosing Wisely
Pamela Rockwell, a family physician and the medical director of Domino’s Farms Family Medicine in the University of Michigan Health System, typically sees about 75 patients per week in her practice. She agrees with many of Dr. Richardson’s and Dr. Lokale’s observations about the AAFP-designated Choosing Wisely recommendations, and she expands on the greater implications for daily practice.
Rockwell notes specifically that the latest guidelines on HPV and cervical cancer have created efficiencies in how she cares for patients. “I find that I’m performing fewer Pap tests and pelvic exams than I was even 5 years ago,” she says. “This has helped my daily practice go a bit faster — now I have more time to talk with my female patients and focus on other aspects of prevention during their annual exams.”
In reflecting on antibiotic overuse, Dr. Rockwell offers this important context:
“During a busy day at the office, when a patient with a viral illness requests an antibiotic, the easiest response is to write the prescription: You make the patient happy, wrap up the visit quickly, and have a better chance of seeing the next patient on time. The alternative is to explain, educate, and justify why you will not prescribe an antibiotic. This takes time and sometimes makes for an uncomfortable interaction. Many patients simply expect antibiotics when they’re sick; many physicians and other health care providers react to that expectation and give out antibiotics freely and inappropriately.
“On the flip side, more patients than ever before in my 20-year career are aware of the overprescribing of antibiotics, and they neither expect nor want antibiotics — that is good. Unfortunately, some parents of young children have gone completely to the other side of the spectrum and do not want antibiotics when their children are ill, even if recommended.”
Choosing Wisely cannot erase these patient-specific realities. What the campaign has done, in Rockwell’s view, is to offer a useful guidepost that physicians must still actively assess as new evidence filters through the medical system and ultimately to patients. That goes not just for prescribing antibiotics, but for all aspects of patient care.
For Dr. Rockwell, trends in the practice of family medicine cannot be boiled down to one-size-fits-all explanations, just as care itself should not be conducted in a one-size-fits-all fashion. She offers this advice: “We still have to teach our family physicians in residency that guidelines are simply that — guidelines. Sometimes common sense, experience, and even a gut feeling can make a difference in our care of patients. Not all medicine is ‘cookbook,’ and not all decisions have a guideline reference; in fact, there often is no guideline to follow for our day-to-day decisions.”
In that sense, Dr. Rockwell emphasizes the importance of deliberate choice as doctors fulfill the Choosing Wisely mission in daily practice. She says, “The more evidence and documents we have to support us, the more we as family physicians can make responsible choices with our patients.”
What is your experience with the Choosing Wisely recommendations in daily practice? How is it similar or dissimilar to the experiences described by Drs. Richardson, Lokale, and Rockwell?