Choosing Wisely, or when to say ‘Whoa!’ to unnecessary medical tests and treatments

A potentially game-changing health-care initiative is underway in the USA. The Choosing Wisely campaign is asking top physicians in different speciality areas (e.g. cardiology, obstetrics, radiology) to identify the top five procedures or tests that are routinely ordered by doctors but not supported by research. More than 60 specialty societies have joined the campaign since its inception in 2012.

This campaign is about more than saving money. Unnecessary tests and procedures not only increase health-care costs, but also put patients at risk. Take CT (computed tomography) scans as an example. A single CT scan delivers between 150 and 1,100 times the radiation of a conventional x-ray. According to Scientific American, the National Cancer Institute estimates that the 72 million CT scans performed in the USA in a single year (2007) could cause up to 29,000 future cancer cases. That increase is equivalent to about 2 percent of the total number of cancers diagnosed nationwide every year. In some situations, CT scans are completely appropriate and the benefits outweigh the risks. Many people, however, receive unnecessary CT scans and, along with them, unneeded doses of radiation. 

On a recent perusal of the Choosing Wisely website, I found no less than 57 lists of ‘Five Things Physicians and Patients Should Question’ created by different medical speciality societies. Patient-friendly versions also have been produced in collaboration with Consumer Reports. The Canadian Medical Association has recently joined the effort and will be producing its own Top 5 lists in partnership with nine Canadian physician speciality societies.

Patients are an important part of the campaign because as care partners, they have a responsibility to ask questions about the pros and cons of different treatment options. And sometimes, patients ask for tests and treatments that are not in their best interests. Two classic examples are requests for imaging (X-ray, CT or MRI scans) in the first few weeks of a new episode of low back pain, or requests for antibiotics (which kill bacteria) when all signs point to a viral infection. Research has shown that physicians can be swayed by patient requests for specific tests or treatments even when they disagree, sometimes because they want to please their ‘customer’ and sometimes because they want to avoid potential lawsuits.

Of course, general lists of things to avoid can never substitute for a skilled clinician making decisions in collaboration with the patient. And the American Board of Internal Medicine (ABIM) Foundation, who is funding the campaign, notes that Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.

Resources

Choosing Wisely Campaign website: http://www.choosingwisely.org

Patient-friendly materials: http://consumerhealthchoices.org/campaigns/choosing-wisely/#materials

When to say ‘Whoa!’ to doctors – a great summary produced by Consumer Reports: http://consumerhealthchoices.org/wp-content/uploads/2012/05/ChoosingWiselyWhoaPkg.pdf

Getting what you want from your doctor’s visit

Building from my previous blog post, in which I offered suggestions for choosing your health care team, today I look at a related issue: communicating effectively with your doctor* (*which could mean your physician, nurse practitioner, or anyone else you are seeing for medical advice and help).

Too many patients and too little time

Today’s doctors are in a big hurry. In many cases, doctors are contractually bound to limit the amount of time they spend with each patient (typically ranging from 10 to 15 minutes) for the purpose of meeting total caseload quotas. Doctors who do not see the number of contractually stipulated patients can be penalized financially or in other ways. Although this system has been criticized heavily from all sides (not least of all, by the doctors themselves), it is the reality under which many health care providers are now seeing patients.

Get clear in your own mind

If you have only 10-15 minutes with your doctor, you need to be thoughtful and organized about your time. You also need to realize that it is as much—or arguably more—your job, as opposed to your doctor’s job, to ensure that you get what you need from your appointment. 

You must plan in advance. First, define what you really want from the appointment. If you are seeing your doctor for a rash, for example, you might want to know whether it’s contagious; or alternatively, you might want a prescription to stop the itching; or maybe you really just want piece of mind that it’s not bed bugs from your recent trip to Paris. The point is: get clear in your own mind what will make the appointment a ‘success’ for you.

Write it down

It never fails to amaze me how often smart, capable people fail to go to their doctor with a written list of issues and questions. (They also fail to bring pen and paper or any type of a recording device, to take note of what is discussed and recommended. But that is a different topic.) With a written list, you will be less likely to become distracted and more likely to get what you want from the appointment. 

Communicate succinctly and effectively

Once you are clear about why you are at the doctor’s office, communicate your goals clearly and repeatedly, before and during your appointment. The essential formula is: “I am here for X issue or problem, and I would like your help via Y action.” Tell the medical assistant or nurse who brings you into the exam room, and repeat it to the doctor. If you plan in advance, it should take you no more than 10 seconds to communicate this information.

For example: “I am here today about this rash. I would like to know if it’s contagious.” Or, “I have been more short of breath lately, and I’d like the doctor to go over my medications and see if there is anything else that can be done to address my asthma.” Practice in advance.

Dealing with multiple issues in one visit

If you have multiple issues you want to address within a single appointment, you might consider starting by saying something like, “I have four things on my list to discuss with you. I am not sure you will have time for all of them. The things I want to cover, in my personal order of priority, are a) a new rash on my chest, b) my ongoing knee pain, c) my ongoing neck pain, and d) new shortness of breath since yesterday.”

Be realistic

You must be realistic about what can be covered within the allotted time. If you don’t know how much time is available for your appointment, ask in advance or while there. Prioritize your list and if necessary, schedule a follow-up appointment to deal with topics that could not be covered fully.

In some cases, your priorities will not match the priorities of your doctor. For example, it is highly likely that any doctor hearing the list outlined in the scenario above would deal first and foremost with your new shortness of breath. That’s because shortness of breath is potentially a life-threatening condition and might indicate a major medical event in progress, such as a heart attack or a blood clot. In situations like these, you need to trust that your doctor is using his/her expertise to reprioritize your list for your overall health.

Finally, it is important to understand that competent doctors practice within the scope of evidence-based medicine, even if that means denying you something you think you want. Good-quality doctors, for example, will not prescribe an advanced imaging test for acute, uncomplicated low back pain, nor will they prescribe an antibiotic for a presumably viral infection. They should, however, explain to you the reasons why this is the case.

 ***

In summary, getting what you want from your doctor’s visit is up to you. Plan in advance, write it down, and communicate clearly.

Resources

Before Your Appointment: Questions Are the Answer. Agency for Healthcare Research and Quality. http://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/questions-before-appointment.html

How Can You Get the Most Out of Your Doctor's Appointment? Center for Advancing Health. http://www.cfah.org/prepared-patient/communicate-with-your-doctors/getting-the-most-out-of-doctors-appointment

Choosing your health care team – Part 1

Much has been written previously about the importance of choosing your doctor wisely. But honestly, much needs to be written on this topic, because smart, savvy people continue to make bad choices, despite all the advice that’s out there. 

Just like any other profession, there are some bad doctors, a lot of reasonably competent doctors, and some excellent doctors.  All are not created equally.  But most people don’t know how to discern the good from the bad.  They make their choices instead based on factors like: proximity to home or work, ease of finding a parking place nearby the clinic, the interior design of the office or the variety of magazines in the waiting room.    

Identifying excellent doctors isn't an easy task

Your choice of doctor is important in and of itself.  It also is important because it typically dictates the broader health care system and the hospital that you will be using eventually if and when needed.  You might have the best doctor in the world, but if that doctor is allied with a poor-quality hospital that has unsafe and unhygienic conditions, then you are in trouble if you ever need to be hospitalized. 

The consequences are significant.  More than a decade ago, the Institute of Medicine estimated that at least 44,000 people, and perhaps as many as 98,000 people, die in United States hospitals each year as a result of medical errors that could have been prevented.

Hence the title of this posting: choosing your health care team.  It is important to choose the right doctor, of course, and that is the focus of today’s posting.  But the broader health care system in which the doctor works is also crucially important.   Even in today’s era of managed care and preferred providers, most of us have a range of picks at our disposal.

Today, I am listing some basic factors you can look into before you meet your prospective doctor.  In future postings, I will discuss some of the things you can consider when you meet the doctor face-to-face; and factors about the broader health system that can serve as clues to the quality of services you can expect to receive.

So don your sleuthing hat and start researching.

Degrees.  In the United States, two professions are licensed to practice medicine: doctors of osteopathy (DOs), and medical doctors (MDs).  Other doctoral-level professions that can practice independently are naturopathic doctors (NDs), doctors of chiropractic (DCs), and my professional group, psychologists (PhDs).  Physician assistants (PAs) and nurse practitioners (ARNPs) are not technically doctors but can serve as primary care providers within larger health care clinics.  Certainly, excellent practitioners can be found within each of these professional groups.  I will nonetheless offer my opinion that MDs are typically the most rigorously trained and best prepared for general health care.  

In addition to the degree, I look at academic reputations of the specific schools and hospitals where the doctor has trained.  This is not a hard and fast indicator, but a clue about the doctor's rigor of training (as well as ability to be accepted into competitive schools or residency programs).  

Board certification. Beyond completing their basic training, doctors must be licensed by the US States in which they work. However, being licensed does not indicate whether a doctor has completed internship and residency, nor whether a doctor is qualified to practice in a specific medical specialty, such as internal medicine, surgery, or dermatology.  One of the best ways to know if your doctor has the qualifications to provide care in a specialty is to find out if he or she is Board Certified by the American Board of Medical Specialties.  I always look for this certification before making an appointment.

Licenses and disciplinary actions. Many US States maintain online databases where you can verify that a health care provider has an active license, and confirm that no official disciplinary actions have been taken against him or her.  An inactive license or a history of disciplinary action is a big red flag.  In some cases, disciplinary actions can be explained by mitigating circumstances but you should do your homework if you see one on a provider’s file.  

Commendations from peers.  In my city, Seattle, a local magazine conducts an annual “top doc” survey of thousands of local doctors.  Each doctor is asked: To whom would you send a loved one for medical care?  The doctors who end up on the final ‘top doc’ list have been selected by their peers as among the very best in their fields.  Most of my doctors have been, or are currently, ‘top docs’.  In locations where such a list does not exist, you can improvise by asking a trusted physician or health care provider in-the-know this same question.

On the other hand, beware of doctor review websites.  You’d think they might be a great source of information.  But in reality, most are unreliable because they are based on only a few reviews, typically from patients who have had either wonderful or awful experiences.  One study showed that only 3% of patients have ever posted an online review of their doctors.  Until these sites are used more widely, they will continue to be inherently untrustworthy.

There is no single factor or information source to lead you to the best possible choice.  But many clues are out there, if you take the time to look for them. 

  

Resources

The website DocFinder contains the licensing background and disciplinary information of physicians and other health care practitioners in addition to physician profile information from US States that have passed physician profile laws.

http://www.docboard.org/aim/

American Board of Medical Specialties maintains a database of board-certified physicians.

https://www.certificationmatters.org/is-your-doctor-board-certified/search-now.aspx

Seattle Magazine’s Top Doctors 2012.

http://www.seattlemag.com/article/top-doctors-seattle-2012-big-list