Just the Facts
Choosing Wisely is an effort to educate physicians and patients about commonly used tests and procedures that are often overused or misused, that make little or no difference in treatment or outcomes, and that can – in some cases – cause harm to patients, says Douglas Wood, MD, chief of the Division of Cardiothoracic Surgery, UW Medicine, Seattle, Wash., and immediate past president of the Society of Thoracic Surgeons.
“For example, in many practices, it became commonplace for patients undergoing major surgery to routinely get cardiac stress testing,” he says. Some surgeons also saw it as a way to protect themselves against potential medical liability.
Now, surgeons have a legitimate desire to identify patients who might have cardiac disease, and for whom pre-op stress testing is beneficial, says Wood. “But in the absence of signs, symptoms or findings of cardiac disease, it isn’t useful. It doesn’t change outcomes; it does not reliably help the surgeon identify disease that calls for intervention. In fact, it may have the counter effect of identifying things that result in further testing or invasive procedures that may result in harm.”
Choosing Wisely can help shape physicians’ behavior, he says. One way is through peer pressure. “Instead of feeling like everyone around you is doing this test in this clinical scenario, it empowers the physician to question it. They can think about being better stewards of resource management, and being more thoughtful about what they’re putting patients through.”
But education is a two-way street, he says. Physicians’ activities are often driven by the expectations of their patients, who might expect or demand certain tests or procedures as a matter of course.
“Part of Choosing Wisely is to elevate the dialogue between patients and doctors,” he says. “It’s a means of empowering and educating patients, and creating opportunities for discussion, so patients can make more informed decisions. It allows patients and physicians to say, ‘We have some evidence that, in this situation, this extra procedure or test may not help, and may cause harm.’
“We shouldn’t be doing tests simply because we can’t think of a reason why not to,” says Wood. “Our country can’t afford to do that – which may be part of the reason our healthcare system is more expensive that that of any other country.
“But it also hurts patients. Doing tests is not benign. That’s one thing patients and physicians don’t understand. They may think, ‘There’s no consequence of doing this CT scan or pulmonary function test.’ The problem is, tests that aren’t indicated can often uncover unimportant things that lead to further testing, some of which may be invasive and result in harm.
“We always ought to ask, ‘Is there a good reason to do this test?’ I always ask our residents and fellows that question. I ask them what they intend to do with the result. If we think things through, we will be more thoughtful about the tests we order. We will help expose patients to fewer unnecessary procedures, and we will use our healthcare resources better.”
Changing long-standing practices doesn’t happen overnight, says Wood. “I don’t think our work is ever done trying to figure out how we can use evidence-based medicine to correctly inform patients and to make thoughtful choices about what is useful in a medical evaluation and what is not. I think this is just the beginning. It’s a great start to a conversation among physicians, and between physicians and their patients.”
Society of Thoracic Surgeons: Five Things Physicians and Patients Should Question
- Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.
- Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
- Don’t perform a routine pre-discharge echocardiogram after cardiac valve replacement surgery.
- Patients with suspected or biopsy proven Stage I non-small cell lung cancer (NSCLC) do not require brain imaging prior to definitive care in the absence of neurologic symptoms.
- Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms.
Source: Choosing Wisely, an initiative of the ABIM Foundation, http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf
Leave a Reply