Two weeks ago I was under the weather. A heavy precipitation event took place in my body (my nose was dripping), I was shivering like a lonely leaf on an autumn night, I felt hot and my muscles ached. A day later, I developed deep, course coughing. Shortness of breath then ensued. In brief, it was a whole catastrophe.
Armed with over-the-counter multi-symptom medications, cough drops, and unfounded optimism, I arrived at work. Around lunchtime, Linda, my nurse, informed me that she talked with my doctor, Dr. Grossman, and that he will be seeing me today, whether I think I need him, or not. And with Linda I do not argue.
I wondered what Dr. Grossman will do to help me. What tests will he order? What medications will he prescribe? I know Dr. Grossman for years. I know him to be a wise doctor. But after reading about the 'Choosing Wisely' initiative I was truly wondering: will my doctor, Dr. Grossman, be choosing wisely?
'Choosing Wisely' is an initiative of the ABIM (American Board of Internal Medicine) Foundation. Its aim is to “encourage physician and patient conversations about overuse and misuse of tests and procedures to help make smart care choices.” On its website, 'choosingwisely.com', you may find multiple lists of 'Five Things Physicians and Patients Should Question'. These lists were developed by societies of medical specialists in the USA. I counted 51 different lists by organizations such as the 'American Academy of Family Physicians', 'American College of Cardiology', and the 'American Headache Society'.
Each list is composed of at least 5 tests or procedures that physicians and patients should question as being unnecessary, and at times even harmful. The American Academy of Family Physicians, for example, advises against an annual electrocardiogram (EKG) for patients without symptoms who are at low risk to develop coronary artery disease (blockage of the arteries delivering blood to the heart itself). They also recommend avoiding antibiotics for children aged 2-12 years with otitis media (ear infection) if they present “with non-severe symptoms where the observation option is reasonable.”
The 'Choosing Wisely' initiative was developed by doctors and their societies, and not by health insurance companies or any governmental body. It therefore does not seem to solely aim at cutting costs, ration medical care, or undermine the patient-doctor relationship. Its declared goal, “to improve patient care through better treatment choices, reduced risks and, and where possible reduced cost,” seems plausible, even noble.
But no initiative, not even the noblest, can pass without criticism. In an article published in the New England Journal of Medicine (February 2014), Dr. Nancy E. Morden and collaborators write that “on the surface,...” it seems that “physicians are willing to make recommendation to improve health care value even against their own financial interests,” but in reality, she notes, most medical societies participating in the 'Choosing Wisely' initiative were more likely to name other specialties' services, rather than their own services, as being low-value. The list of the 'Otolaryngology – Head and Neck Surgery', for example, includes three imaging tests (which are read by radiologists), but not even one statement on procedures such as tonsillectomy and tympanostomy ('ear-tube placement') “despite decades of literature on wide variation and overuse” of these procedures.
To me, the 'Choosing Wisely' initiative is a welcome step in the right direction. So much of what doctors do may be unnecessary, wasteful, even harmful. The temptation to 'do more' is strong: patients want their doctors to 'do something', they want to be evaluated, they want to be treated; and administrators want doctors to 'do more' in order to generate the income their hospitals and health systems need to survive. So when I read the second item on the 'Choosing Wisely' list of the 'Society of General Internal Medicine' that states “Don't perform routine general health checks for asymptomatic adults,” I feel relieved, for doctors are moving in the right direction, in control, holding themselves back, avoiding unnecessary care that may do more harm than good.
Dr. Grossman listened carefully to my story. He thoroughly inquired about my symptoms. He examined my throat and carefully listened to my lungs and heart. He did not order a chest X-ray, nor did he prescribe antibiotics. He told me to rest a little more and to come back if my symptoms do not improve. He is my doctor—a doctor who is choosing wisely, for I am feeling much better now.