Alan Cassels is a drug policy researcher at the University of Victoria and a regular contributor to the blog. He is also the author, most recently, of The Cochrane Collaboration: Medicine’s Best-Kept Secret. He tweets as @AKEcassels.
Do you really need a CT scan for a headache? Or a test for Vitamin D?
Maybe not, yet these are a few of the hundreds of examples of medical tests or treatments that are given to patients but may be unnecessary and even possibly harmful, according to the folks behind Choosing Wisely, an initiative that began in 2012. The organization “seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures.”
Thanks to Choosing Wisely’s ever-widening work, questioning tests and procedures is now becoming more accepted. Users of the site can review lists of hundreds of such tests or treatments that deserve to be questioned, provided by dozens of medical societies in the U.S. and nearly 20 other nations.
Right now, with nearly 500 recommendations from more than 70 specialty groups in the U.S., it’s worth taking a retrospective look at what has been achieved. You can read more about its history here.
Choosing Wisely, which is funded by the American Board of Internal Medicine Foundation and has a partnership with Consumer Reports, initially released a series of “top five” lists from nine different specialties. This inspired other societies to do their own bit, based on a shared interest in identifying what is being offered to patients that may be unnecessary or harmful.
Dr. Wendy Levinson, writing in the BMJ, said that the Choosing Wisely campaign “emerged in the United States with the intention of galvanizing physicians to reduce unnecessary care,” and the medical professor from the University of Toronto is one of its most vocal supporters.
As the Chair of Choosing Wisely Canada, Levinson attributes the growth of Choosing Wisely to a number of factors, including the fact that the organization is highly collaborative and grassroots–engaging individual physicians and asking for their own input in critiquing of their individual specialties.
The uptake in Canada of Choosing Wisely was “shocking” and the enthusiasm it generated surprised Levinson.
It’s “an idea whose time has come,” she said, and it was warmly embraced because it’s not “top-down.”
“Our approach is that we want to enable others,” she told me, adding that Choosing Wisely is not about pushing a vision on people. “We are trying to develop and support leaders in this area. We are bottom up, grassroots.”
Dominic Lorusso, the Director of Health Partnerships at Consumer Reports, has been working with Choosing Wisely since its inception. He said it has overlapping goals with his organization–that is, patient education and getting people the appropriate information.
The appeal to his organization is that the lists are “vetted by the specialities, and the recommendations are based on science.” For him, however, the most important thing is the empowerment of patients, helping them have a dialogue on what is unnecessary or harmful.
“At the Consumer Reports side of the house, the big part is engagement,” he tells me from his office in New York. “We started out with 11 consumer partners working on these recommendations and that has grown to 50–they disseminate the resources to their groups.”
For example, more than 200,000 wallet cards on the “Five Questions to Ask Your Doctor Before You Get Any Test, Treatment or Procedure” have been distributed. They are:
Lorusso believes that the interest in Choosing Wisely has grown quickly because ”people are not comfortable speaking with their physician. It’s not ingrained in culture, and doctors are busy and don’t have time for questions.”
The solution, he said, is to make things simple, like a list of questions one could ask. “The impact of Consumer Reports is on awareness. We think that it’s OK to ask questions.”
It’s probably too early to say if Choosing Wisely is having any impact, but it is certainly being studied to see where it may be impacting patient care. A survey found that in Canada, about 1 in 10 patients are aware of the campaign (see page 12 of this report).
A recent report published by the Canadian Institutes of Health Information, Unnecessary Care in Canada, found that about 62% of survey respondents feel there is too much unnecessary health care, such as giving routine mammograms to average-risk women in their 40s.
There are signs of growing attention to overtreatment, perhaps best exemplified by Preventing Overdiagnosis Conference, holding its fifth annual conference this August in Quebec City. The topic occasionally makes it way into media reporting, too. Consumer Reports has covered the issue extensively in articles, such as this one on The Dangers of Too Many Heart Tests, and just recently the New York Times looked at the overdiagnosis of subclinical thyroid disease in older adults.
As for critical examinations of Choosing Wisely, there have been past criticisms, including by me, (who didn’t think the initial recommendations went far enough), the New England Journal of Medicine, (also questioning the politics of developing “low-value” lists) and a Science blog that said it wasn’t very effective, at least not three years after its inception. This last criticism was based on a very early study of several of Choosing Wisely’s recommendations, published in JAMA, looking at health administrative data related to seven “low-value services.”
As journalists, it’s important to examine the problem of “low value” care, and to look at solutions that empower patients and clinicians to routinely question orthodoxy in medicine. The questions recommended by Choosing Wisely are the same kinds of things journalists should routinely question when a news release or other PR effort is promoting a new test, drug or procedure: How well is the thing studied, are the benefits likely to exceed the harms, what are the costs, and how independent are the sources of information? See HealthNewsReview.org’s 10 criteria for more.
In terms of grassroots impact, what happened when Seattle clinicians at Group Health consulted with Choosing Wisely is illuminating. They sought to help physicians understand that patient requests about a test or drug simply may be an attempt to get additional information–and shouldn’t be treated as if the patient wants the test or drug. It was described this way: “Group Health first helped physicians and other providers change their perspective on the situation.”
For example, they asked doctors to look at patient requests for unnecessary treatment as partially informed inquiries, not a demand for services. Clinicians were encouraged to listen and show empathy to the patient, acknowledge symptoms and ask what could be done to manage discomfort. Then the physician provided better information and educated the patient.”
In the end, Choosing Wisely is all about asking better, more vital questions. The fact that specialists are questioning what they do–and patients are encouraged to more deeply question that newest drug, test or treatment–should give journalists more ammunition to ask deeper questions as they work to engage everyone about health and healthcare.