Flip No. 15

Reduce unnecessary health treatments

Leverage Choosing Wisely to demonstrate impact of unnecessary interventions.

By Flip the Clinic

Typically, physicians tell patients what tests, medications, or therapies they need to get better. But in 2011, the ABIM Foundation challenged medical societies to come up with a list of five tests, treatments, or services that physicians and patients should actively question. They called the initiative Choosing Wisely. Its goal was to encourage conversations between physicians and patients about avoiding unnecessary care that won’t benefit the patient and could cause them harm.

Nine organizations, including the American Academy of Family Physicians and the American Academy of Allergy, Asthma & Immunology signed on initially. Each participating organization went through its own rigorous selection process to first collect suggestions—including engaging their members—for what might be overused or unnecessary before refining them to the top five deemed most salient in their field. The initial lists of “Five Things Patients and Providers Should Question” were published in April, 2012. Consumer Reports partnered with the ABIM Foundation in the effort to develop patient-friendly materials based on the society recommendations and is working with consumer groups to disseminate them widely. Today, over 60 different medical academies have joined Choosing Wisely by compiling their list of five things to question.

When an estimated 30 percent of all health care spending is wasted and unnecessary medical procedures could truly do more harm than good, Choosing Wisely aims to promote conversations between patients and providers.

To support this goal, the ABIM Foundation funded the creation of modules that teach physicians how to talk to patients about treatment plans that have been flagged, like a CT scan after a patient faints or routine cancer screenings for patients on dialysis. With proper physician training, these discussions can be completed in just three minutes of clinic time. Here’s how the ABIM Foundation suggests physicians should talk to their patients about Choosing Wisely in just five easy steps.

All of Choosing Wisely’s invaluable lists of “Five Things Physicians and Patients Should Question” can be found at ChoosingWisely.org.

1. Deliver Clear Information
Physicians often overestimate the amount of time they spend educating patients and underestimate just how much patients want to know.
—Explain your recommendations using the Choosing Wisely guidelines as a reference.
—Keep explanations simple and avoid medical jargon.
—Acknowledge that guidelines are not “one size fits all.”
—Discuss key evidence about risks, benefits, and research supporting the guidelines.
—Use written materials to support your recommendations.

2. Elicit Concerns
Ask about a patient’s concerns regarding a certain treatment (or lack of it) in order to address them.
—Simply asking about patient concerns is often the most effective way to start the conversation.
—Sometimes commenting on non-verbal behavior will encourage the expression of important concerns. Ex: “You look upset…”

3. Empathy
When patients are making health decisions, they often seek physician support. Physicians can communicate that they’ve heard and care about a patient’s concerns by using empathetic comments and actions.
—Non-verbal skills: Eye contact, head nodding, touching
—Reflection: “I can see you are upset by this.”
—Legitimation: “It is normal for people in your situation to feel this way.”
—Attentive Silence
—Statement of Partnership: “We will work together on getting you to feel better.”

4. Confirm Agreement
Make sure that the patient is content with their decision.
—Briefly summarize treatment plan.
—Ensure patient satisfaction and agreement.
—Provide a clear contingency plan and ask the patient to alert you if any red flags arise.

5. Provide additional information
When patients are more invested in their own health, they’re more likely to follow through with treatments. 
—Provide video or written educational information.
—Arrange resources, referrals, and prescriptions and schedule a follow-up.

Case Studies

Kaiser Permanente
At Kaiser Permanente in Colorado, the associate medical director requested that all the clinic’s department heads review Choosing Wisely’s recommendations. Kaiser decided to focus specifically on the overuse of imaging with the goal of finding out whether their practice patterns were consistent with the relevant lists. An internal review revealed that up to 25 percent of physician recommendations for imaging based on the common headache may have been unnecessary.

Jama International Medicine
An article in JAMA Internal Medicine published in 2011 found that unnecessary activities in primary care, which range from prescribing brand name medications to ordering superfluous tests, cost over $5 billion annually.