Seeing patients at my local health clinic, I recently had a fairly typical day for many doctors. I saw a child whose parents had been advised to give him a cough-and-cold medicine for his cold, a woman who had been prescribed the antibiotic azithromycin for her viral upper respiratory infection, a high-school teacher who had been prescribed an antibiotic for her pink eye (which wasn't getting better), and a man who had been told he was due for a repeat colonoscopy five years after his previous, completely normal one.
What's wrong with this picture? Cough-and-cold medicines are not recommended for children because they do no good and because they can cause harm to children. Antibiotics like azithromycin are completely ineffective against viral infections and carry a risk of serious side effects. Likewise, antibiotics don't work for pink eye—a condition almost always caused by a virus. That's why my patient hadn't gotten better in the two days she had been using the drops that burned her eyes each time she put them in. And current guidelines, based on research, recommend that patients with a normal colonoscopy can wait 10 years before their next one.
So why was the prior medical care these four patients received so at odds with treatment guidelines? Two patients had been seen in the emergency room, one was treated by a fellow provider in my health center, and one by his prior specialist, a gastroenterologist. Were these other clinicians who had made these inappropriate decisions ignorant of the science? No, I don't think so. They were probably caring doctors and advanced-practice nurses who truly wanted to help their patients.
So why would they make such choices that, in fact, ended up not helping their patients and even putting them at risk for untoward events? Some will say it's because the patients expect the treatments they received. However, multiple studies have shown that most of the time the patient is not expecting the prescription for an antibiotic that that the doctor thinks the patient wants.
Sometimes it's because the doctor wants to do something and mistakenly believes that only a prescription equates to doing something. Other times it may be because the provider is in a hurry and thinks a prescription can replace a conversation and save time. And we must acknowledge that sometimes it is to the financial benefit of the physician to recommend a procedure more frequently than it really is needed. Whatever the reasons, the results show up as the widespread overuse of medical care in the United States, a big problem for several reasons.
First, overtreatment and mistreatment leads to actual harms to patients, sometimes even death. One-third of patients told they needed heart bypass surgery did not need it, according to a study by the Harvard School of Public Health and the RAND Corporation. Nearly 300,000 women have healthy ovaries removed unnecessarily during hysterectomies, subjecting these women to premature cardiovascular disease and osteoporosis as they age, another study found.
And overtreatment wastes money, money that could be spent on expanding health care coverage for millions of people who still lack access to affordable care. And money that could be spent on other important social needs like housing and poverty. In a take-off on the old TV quiz show, “The $64,000 Question,” public health researchers Fuchs and Milstein posed the $640 billion question. They noted that there are individual physicians and health care organizations in the U.S. that deliver high-quality care at roughly 20 percent lower cost than the U.S. average. If the rest of the U.S. health care industry followed their example, we could save $640 billion annually—more than enough to achieve universal coverage.
In 2009, the American Board of Internal Medicine (ABIM) Foundation launched a program providing small grants to advance principles of the Physician Charter, which calls upon physicians to work toward the wise and cost-effective management of limited clinical resources as an ethical commitment to professionalism, and in 2011, members of the progressive physician’s group National Physician’s Alliance (NPA) field-tested proposed "Top 5" lists of things that primary care physicians in family medicine, internal medicine, and pediatrics, should not do and then published our results.
The idea that a group of doctors could come up with a list of five things they shouldn't be doing to patients was a revolutionary notion that grabbed the attention of the lay media, resulting in extensive coverage from the Wall Street Journal to Vogue. The ABIM Foundation was so pleased with the success of this NPA project that they decided to fund and launch a major effort expanding the concept beyond primary care to all medical specialties. The result was the Choosing Wisely campaign that now includes more than 60 medical specialties and has even started to be taken up by health disciplines outside of medicine, such as physical therapy and dentistry.
Winning the hearts and minds of health care providers and the public won't be easy. Powerful forces stoke the engines of overuse—a fee-for-service system that rewards doing more, pharmaceutical companies that want to sell more drugs, hospitals that want to fill beds, and providers who want to do something—all regardless of whether that's really in the best interest of patients.
And winning over patients could also be just as hard. Until patients are better informed about their care, it can be hard not to feel suspicious when your doctor tells you to “wait and see if this symptom clears up on its own” even if that is the best treatment.
That’s why Choosing Wisely has started to create resources to help patients understand when less care can be better, and safer. Consumer Reports has joined the Choosing Wisely campaign and is producing high-quality handouts for patients on each of the items on the "Top 5" lists. Having a trusted group such as Consumer Reports supporting the campaign serves a vital function in blunting any fear that these recommendations in any way represent an effort to ration care. Rationing means denying patients needed and beneficial care; Choosing Wisely focuses on avoiding unneeded, wasteful, and potentially harmful care.
As the health care system continues to change, patients and consumers have the chance to become more involved in decisions about their care. Many consumers resort to the internet to research their care options already. And they need reliable, trusted sources of information. The consumer-friendly resources available through Choosing Wisely are a good place to start.
Consumer advocates can help publicize these important resources for the constituencies they serve to help them learn more about high quality health care. Furthermore, consumer advocates can encourage consumers to bring these resources to their doctor visits, and train them to have open discussions with their providers about when less care is the right choice. Will an antibiotic really help me? Are there risks to getting a scan that I don’t know about? When should my kids get their eyes checked?
And as health care policy continues to change, advocates can help ensure that these recommendations are considered as payment and reimbursement incentives are improved. Consumer advocates must be vigilant, to help ensure that as overtreatment is reduced, the savings that should result are used to improve the value of health care for consumers.
Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consultant