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Opinion: Emergency Physicians Challenge Implementing Choosing Wisely Recommendations at Bedside

By Kevin M. Klauer, DO, EJD, FACEP | on May 18, 2016 | 2 Comments
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Choosing Wisely
ILLUSTRATION/PAUL JUESTRICH; PHOTOs shutterstock.com

Editor’s Note: We received many responses to February’s article, “Time to Walk the Walk: Choosing Wisely and knowledge translation” by Dr. Klauer. Here are a few of the comments from the emergency medicine community.

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ACEP Now: Vol 35 – No 05 – May 2016

I enjoyed reading your article and agree! For me, the challenge remains how do we not give a patient what he/she wants (regardless of need!) and still obtain 5/5 on our patient satisfaction scores?

Patients expect antibiotics for everything and new exciting scans and tests, even if the onset of the symptoms is exactly five minutes longer than their door-to-provider time. We expect them to pay a ridiculous copay in credit card or cash at the time they are seen. (My employer’s plan has a $250 copay for every ED visit.) Then we “refuse” to give them what they want, and we expect them to be happy for it and give us positive reviews? I have worked in several large EM groups and have heard numerous clinicians state they have dramatically increased their patient satisfaction scores by 1) ordering every scan patients wants and 2) giving patients any prescription they want regardless of indication, medical necessity, or need.

For many years, providers were able to tell patients, “This is not in your best interest and can even be detrimental to your health,” “Studies have shown …” when discussing tests, treatments, scans, and prescriptions. “No, ma’am, your child does not need a CT scan of his head after being shot in the head with a Nerf gun from across the room. His risk of cancer from the scan far outweighs any potential benefit.” You can explain and produce research until the cows come home, but Mom is in the ED to get a CT scan, and sending her home without it leads to an unsatisfied patient experience, resulting in patient complaints and poor satisfaction scores, and directly effects both your income and the income of your employing institution.

My family went out to eat last night. If the server had refused to serve the food I ordered because I am expanding at the waistline and hundreds of studies and years of research had shown this particular dish to be detrimental to my health, I likely would have refused to pay the bill, skipped the tip, and posted something unflattering on a website reviewing that establishment. Let’s be honest: Most patients are not in the ED to hear about what is best for them or what a study shows. Patients are in the ED to get what they want. And if they don’t, they will be unsatisfied with their visit, period. If IV vancomycin “cured my sniffles in 30 seconds flat last time I was here,” then they expect IV vancomycin at every visit for those complaints.

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Topics: Choosing WiselyEmergency DepartmentEmergency MedicineEmergency PhysiciansImaging & UltrasoundLab TestOpinionPatient CarePractice ManagementQuality & Safety

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About the Author

Kevin M. Klauer, DO, EJD, FACEP

Kevin M. Klauer, DO, EJD, FACEP, is Chief Medical Officer–hospital-based services and Chief Risk Officer for TeamHealth as well as the Executive Director of the TeamHealth Patient Safety Organization. He is a clinical assistant professor at the University of Tennessee and Michigan State University College of Osteopathic Medicine. Dr. Klauer served as editor-in-chief for Emergency Physicians Monthly publication for five years and is the co-author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals. Dr. Klauer also serves on the ACEP Board.

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2 Responses to “Opinion: Emergency Physicians Challenge Implementing Choosing Wisely Recommendations at Bedside”

  1. June 19, 2016

    Myles Riner, MD Reply

    One of the reasons that ACEP’s Choosing Wisely campaign has not been widely adopted is, in my opinion, a lack of useful and necessary materials and tools to assist ED physicians and staff in implementing these shared decision-making recommendations. As a member of the ACEP CW Delphi panel and Cost Effective Care Task Force, I tried to get the ACEP Board to extend the task of the TF to include the production of such a ‘tool kit’, and this suggestion went nowhere. I then proposed to organize the development of this toolkit as a for-profit enterprise, and license from ACEP the supporting materials that were developed by the TaskForce. This toolkit would have included: education materials for staff and patients; videos; scripts for providers; targets and metrics for monitoring; supporting handheld apps; templates for feedback forms, dashboards, disclosure notices and even shared savings incentive program guidelines. This proposal to the Board was also turned down, apparently because the rules prevent committee or task force members from using committee work product in this way. I wonder how many times these rules have discouraged participation in similar ACEP projects? Other specialty societies have developed similar materials to help their members adopt CW strategies, but ACEP was content to put out its list and a few one-pagers and leave it up to members and EP groups to find their own way. Such a toolkit might have helped EPs to overcome many of the objections and impediments mentioned in response to this article. Opportunity lost.

  2. June 19, 2016

    Mark J. Cotter, PA-C Reply

    Thanks for references debunking the belief that “giving patients what they want” is the key to improved patient satisfaction scores, but is what I instead see as a lazy way out of doing our job. As health care providers, we are charged not with “satisfying” our patients, but taking care of them. It certainly is easier to write for an unnecessary prescription or test than it is to explain the reasons they may not be in the patient’s best interest. Sure, some remain unconvinced, and sometimes I order/prescribe things that patients have much more faith in than I, but the vast majority of my patients express gratitude and relief that I am a caring provider, even if they don’t get what they initially were seeking. Thanks for advocating we do the right thing.

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