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Monday, May 7, 2012

Choosing Wisely--a campaign to save healthcare resources by not doing stupid things

The most recent edition of the Journal of the AMA features an opinion article about a campaign to highlight the top 5 probably useless, dangerous and overused medical interventions for various medical specialties. This is the link:, The authors,  Dr. Christine Cassel, the CEO of the American Board of Internal Medicine and Dr. James Guest, the CEO of the Consumer's Union, discuss the process that has led up to this approach.

In 2002 US and European internists came together to create a document entitled "Medical Professionalism in the New Millennium: A Physician Charter." This put into print a set of goals that were intended to spark various projects to improve what physicians do.  The primary principles were that patient welfare goes first, that patients have the right to autonomy in defining their medical care and that physicians should be held to behave in a way that promotes social justice, including fair distribution of limited and finite medical resources. Out of the charter rose a growing impetus towards determining and promoting high value and cost conscious care.

The Choosing Wisely campaign is aimed at physicians and patients and is readable and understandable, not talking down to either group, but sufficiently well worded and detailed to be of use. The groups that worked on this decided that instead of tackling all of the things that we do that are useless, choosing the top 5 most egregiously stupid interventions in each participating specialty would be an excellent start and could save billions of dollars. The website is and it doesn't run very well on Google Chrome, but seems to do great on Internet Explorer. The egregiously bad top 5 for internal medicine are that doing plain film x-rays for low back pain without red flag symptoms adds nothing, that getting a preoperative chest x-ray when a person has no lung symptoms is a bad idea, that doing cardiac stress testing just to make sure everything is ok in a person with no symptoms and low cardiac risks is liable to give bad information and that doing a head CT or MRI scan because someone faints makes no sense and doesn't help. The final one is that a normal d dimer blood test is good enough to rule out a pulmonary embolus in someone felt to be at low risk, without performing imaging studies. Oncology has their own set of don't-do's as does nephrology and a total of 9 medical specialties. Some of them overlap. Some are obvious and probably don't go far enough, like the nephrology recommendation that the patient and family should all sit down and discuss options before the patient starts dialysis. My guess is that consensus finding guided the wording in many of these. The recommendations are intended not just to avoid wasting resources, but also to limit risk to patients including radiation exposure and intrinsic risks of medications and invasive procedures.

This website adds a great deal to the resources available for good shared decision making about medical interventions between patients and providers. It's an excellent start.

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