—William Fisher, MD
Explore This IssueACEP Now: Vol 35 – No 05 – May 2016
Without tort reform, Choosing Wisely are just empty words. Nobody is rewarded for ordering less. Start from the beginning. If Choosing Wisely was accompanied by incentives that didn’t conflict with the rewards of the current system, perhaps it would be more successful.
Perhaps, I didn’t “choose wisely” when I chose to write an article about the Choosing Wisely campaign. After climbing out from underneath the pile and dusting myself off, I’m ready to address the great comments we received on this topic.
Important conversation is exactly what we need for the specialty to formulate a consolidated and unified voice on any given issue, including Choosing Wisely. ACEP made the decision to join this campaign for a variety of good reasons. However, participation is a long way from fully understanding the implications of such a program at the bedside. The ACEP leadership will rely on its members to help fully inform their perspectives on the experiences and concerns of emergency physicians with respect to Choosing Wisely.
Joel, thank you for the support. Although I think vancomycin is a pretty big gun for the common cold, I get your point. Patients often have unrealistic expectations that find their roots in assumption and mere coincidence as opposed to cause and effect; nonetheless, such expectations persist. Compounded with the pressure of performing to experience-of-care metrics, this somewhat creates the perfect storm. However, this is only true if you believe two things: 1) patient expectations cannot be changed, and 2) patients value the “test” over sound medical advice. Personally, I don’t believe either of these to be true. Although this perspective may not have much of an audience, it may be worth sharing. Changing preconceived notions about what care should be provided is all about education, and once effectively educated to the lack of utility of what they want, including any negative consequences, most reasonable patients will opt for appropriate care.
I take exception not with you but with the premise that ordering more tests, prescribing antibiotics, and—let’s add one more myth—prescribing more opioids result in better scores. Joel, you’re in good company. Freda also raised this important and common concern. I respect it but simply have a difference of opinion.
Dowd et al reported that increased utilization did not correlate with improved scores, while Froehlich and Welch noted that in patients who expected diagnostic testing, “provider humanism” was the sole significant predictor of patient satisfaction.1,2 Regarding prescribing unnecessary antibiotics, Mangione-Smith et al found that good communication influenced parental satisfaction regardless of whether antibiotics were prescribed or even expected.3 Finally, Schwartz concluded, “However, in the multivariable analysis, receipt of analgesic medications or opioid analgesics was not associated with overall scores.”4 I expect some will challenge the quality of this evidence refuting that satisfaction is linked to tests, antibiotics, and opioids, but to them I ask, is there higher-quality evidence proving the hypothesis that they are linked?