Until this issue is resolved, providers will read articles like this, nod their heads in agreement, and then sadly ignore these recommendations in favor of income and employment security.
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ACEP Now: Vol 35 – No 05 – May 2016—Joel
In order to implement these recommendations, every physician or health care provider must feel assured that he/she isn’t missing a red flag or overlooking a finding that would indeed indicate the utilization of one of these tests. However, in order to achieve this degree of assurance, one must perform a good history and physical examination. That doesn’t happen nowadays.
The “history” consists of a few perfunctory questions asked from a computer template that often has little association with the top two or three conditions in the patient’s differential diagnosis. It is typically acquired without the physician ever looking at the patient and without giving the patient an opportunity to interject a comment.
The physical exam—if done at all—consists of a “stethoscope tap,” in which the diaphragm of the scope is placed on the right and left upper chest for less than one second in each location, and the “belly pat,” in which one hand is placed on the patient’s abdomen—usually with the patient fully clothed, without even indenting the contour of the abdomen. In fact, you can find more and more physicians who pride themselves on not doing a physical examination, claiming that a physical exam is a dinosaur and no longer pertinent in a digital, technologically advanced world. I recently attended a symposium in which a number of speakers actually mocked physicians who still do physical exams.
Thus, the only way left nowadays for many physicians to feel assured that they are not missing a red flag is to order an abundance of unnecessary tests that would have been obviated by a decent history and physical examination.
—Jerry W. Jones, MD, FACEP
Mequon, Wisconsin
The patients who come to the ER want tests, not a dissertation on why they are not necessary. This is the mindset. Every survey has shown that more tests, even negative, generate better evaluations and ensure your job.
—Freda Lozanoff, DO, FACEP
Furlong, Pennsylvania
You guys just don’t get it. Choosing Wisely is a euphemism for saying, “help decrease the cost of medical care and be liable for any of your mistakes.” Without tort reform that gives me complete protection if I follow Choosing Wisely and safe harbor guidelines, I do not intend to modify my practice in any way. I’ll say it again, I will not participate in any program that increases my medical liability. When legislation is passed that says I cannot be sued if I follow Choosing Wisely or safe harbor guidelines, I will be happy to modify my practice.
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2 Responses to “Opinion: Emergency Physicians Challenge Implementing Choosing Wisely Recommendations at Bedside”
June 19, 2016
Myles Riner, MDOne 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.
June 19, 2016
Mark J. Cotter, PA-CThanks 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.