Perspective on recent recommendations from the ABIM Foundation:
A group of nine medical specialty societies, collectively called the Choosing Wisely initiative, has recommended that doctors perform 45 common tests and procedures less often. Eight other specialty societies are preparing to follow suit with similar recommendations. These changes touch on tests performed for diagnosis, risk assessment and screening, as well as treatments for numerous conditions.
All I can say is, it’s about time!
We physicians often order tests or prescribe treatments because we’ve “always done it this way” or because we’re afraid of missing something. We also don’t always appreciate that tests come with a cost, both financial and otherwise. The fact is, many of the things we do in medicine don’t necessarily have a basis in science or truly provide value to our patients. By value, I mean providing useful information that aids in the treatment of a patient or effectively treating a condition with minimal or no harm to the patient.
A recent study of hospital patients demonstrated that when doctors are given information about how much various tests actually cost, they order less of them. When you know there’s a cost associated with something, it makes you stop and think about whether or not it’s worth it. In this study, ordering fewer tests didn’t result in poorer outcomes, just lower costs.
In my particular field of expertise, cancer care, we see this all the time. We order lots of x-rays and scans, often getting the same information in multiple forms. We consider treatments that may offer little benefit and carry significant risk of harm.
By critically looking at what actually benefits my patients and what actually can be supported by science, I have changed my practice over the last several years. In the absence of a history or symptoms of heart disease, I don’t routinely order preoperative cardiac stress tests any more. We used to think it made a difference in outcomes. Now we know it doesn’t. I don’t routinely order chest x-rays after certain procedures, because I’ve never had one return a significant result that changed how I treated a patient. I don’t order daily labs on patients in the hospital who’ve undergone lung surgery (unless there’s a specific reason to do so). After successful surgery for lung cancer, I have a frank discussion with my patients about how best to monitor for recurrence, because the scientific evidence doesn’t really support any one approach.
As physicians, we need to always question what we are doing for our patients. Are we doing things that help us make better decisions and recommendations and that improve outcomes? In other words, does what we’re doing create value?
Sometimes more care is a good thing. Sometimes it’s just more.
Here at FMH, we are looking at cancer care from top to bottom. Our physicians are looking at the ways we diagnose, stage and treat cancer. We want to make sure we are doing things in a way that maximizes the benefits our patients, minimizes harm and doesn’t add unnecessary costs to the care we provide. We want to maximize the value we provide to our patients and our community. We’re doing this because it makes sense. We’re doing this because it’s the right thing to do.