In my opinion, two of the emergency physician’s greatest tools are bedside education and communication. When you know why they want a test, perhaps you can change expectations. Just telling people they don’t need a test isn’t education; it’s a demoralizing smackdown. Your question reminds me of a patient I saw a couple of years ago who had been experiencing a cough for a week. He was adamant about getting a chest X-ray. After explaining the lack of utility of a chest X-ray, he wasn’t the least bit dissuaded. I asked, “What concerns you about your cough? Why do you want an X-ray?” He replied, “My father had a cough, and when they finally did a chest X-ray, they diagnosed him with lung cancer.” This wasn’t about the test; it was about an uneducated fear of lung cancer.
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ACEP Now: Vol 35 – No 05 – May 2016In my opinion, two of the emergency physician’s greatest tools are bedside education and communication. When you know why they want a test, perhaps you can change expectations. Just telling people they don’t need a test isn’t education; it’s a demoralizing smackdown.
Despite attempts to educate them, some patients may not change their minds. However, even if you acquiesce to some of those demands, you still have reduced unnecessary testing for so many more. Choosing Wisely provides us with a tool. It is not only an evidence-based educational tool but an authority that supports your advice and to divert the heat toward.
Jerry, very interesting perspective, and I completely agree. The advances in and availability of medical technology have fallen victim to the law of unintended consequences. With overreliance on diagnostic technology, the art of physical examination has begun to erode.5,6 Testing used to confirm the concerns developed through a thorough history and physical examination, but now, all too often, it’s the other way around; the physical examination takes a back seat to the diagnostics. The “right” tests complement a good history and physical examination, but more tests will never be a substitute for the art of bedside diagnosis.
Bill and Alise, I sense your frustration and suspect you speak for a great many who are simply sick and tired of well-intentioned bureaucrats who have developed a financial conscience, demanding fiscal responsibility and stewardship while asking physicians to do much, much more with far, far less. Your comments strike the most important points with laser-like precision.
“Help decrease the cost of medical care and be liable for any of your mistakes.”
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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.