Change of Habits
Choosing Wisely isn’t just an effort to reduce tests and procedures that are likely to have little or no impact on outcomes, says Eric Bass, M.D., MPH, professor of medicine at the Johns Hopkins University School of Medicine and Bloomberg School of Public Health, and president of the Society of General Internal Medicine. It is also an effort to consider the impact of tests and procedures that have the potential to cause more harm than good. SGIM is comprised primarily of academic general internists.
One SGIM recommendation – to weigh the benefit of cancer screening in adults with a life expectancy of less than 10 years – demonstrates the point. Consider screening colonoscopy, says Bass. “At some point, you wonder how much you’re helping an older person with a short life expectancy by putting him or her through the prep and procedure of a colonoscopy.”
Increasingly, physicians are factoring in life expectancy when making recommendations to their patients, he says. “But it’s still a tricky recommendation, because it’s difficult to predict what an individual’s life expectancy is. It can be a challenging conversation to have with a patient, though some are receptive, and are reluctant to be put through invasive testing when they realize they may not live long enough to derive the full benefit.”
Another SGIM recommendation – that physicians forego routine pre-operative testing before low-risk surgical procedures – is focused on procedures that tend to have little impact on outcomes. Bass’s colleagues at Johns Hopkins conducted a large study of the benefits of pre-op tests – such as a CBC, chemistry panel, EKG, chest X-ray, etc. – before cataract surgery. “That study showed there was really no benefit in that setting,” he says. “There are some patients for whom preoperative testing is a good idea, but it’s not something that needs to be done routinely, without considering the individual’s health status and risk.”
A third SGIM recommendation – to refrain from performing routine general health checks for asymptomatic adults – demonstrates the challenges associated with changing longstanding habits on the part of physicians and patients. “It addresses something we’ve done as part of our traditional approach to care,” says Bass. “Some evidence suggests that routine health checks reduce patient worrying and may facilitate the administration of preventive measures. But apart from that, they don’t add much value in terms of hard clinical outcomes.”
But the recommendation about routine checkups comes with some big caveats – caveats that apply to many Choosing Wisely recommendations. “It assumes the patient has an established relationship with a primary care provider he or she trusts,” and that the two can discuss the overall value of a routine checkup, says Bass. That discussion would consider the potential benefits of such a checkup, such as discovering or keeping tabs on potentially significant lifestyle issues or mental health concerns that otherwise might go unnoticed or uncared for.
“The best way to think about this recommendation is this: You should have an honest conversation about the best time to come back for a visit,” he says. “If you’re healthy and asymptomatic, and you have a doctor you can easily reach [if needed], you may not need to come back for a checkup every year. But for other people, based on risk factors and lifestyle, it may be important to come back, even more frequently than every 12 months.”
Change can be difficult. “A lot of it comes back to our habitual approach to care, and not paying enough attention to thinking about the value of the care we’re providing,” says Bass. SGIM’s new tagline – “Creating value for patients” – as well as Choosing Wisely, are vehicles to advise physicians and train the next generation to think carefully about the value of the care they provide, he adds.
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Society of General Internal Medicine: Five Things Physicians and Patients Should Question
- Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.
- Don’t perform routine general health checks for asymptomatic adults.
- Don’t perform routine pre-operative testing before low-risk surgical procedures.
- Don’t recommend cancer screening in adults with life expectancy of less than 10 years.
- Don’t place, or leave in place, peripherally inserted central catheters for patient or provider convenience.
Source: Choosing Wisely, an initiative of the ABIM Foundation,
http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf