Primum non nocere.
First, do no harm. Nearly every medical student in our nation pledges to abide by these words as part of the Hippocratic Oath upon graduation from medical school. Harm is typically interpreted to mean physical or emotional harm, and certainly we strive to avoid these. Additionally, there is another harm we can inflict on our patients and ultimately our country, and that is financial harm.
The United States spends more money on health care per person than any other country in the world, devoting over 17% of our national economy to health care expenses. Underlying reasons include spending proportionately more on health care administration (which commands 25% of our health care dollars), insurance, medications, tests and procedures than other countries. Despite spending more, our health outcomes are among the worst in the world; in a 2014 comparison to 10 other industrialized countries looking at quality and efficiency of health care, the US came in dead last overall.
Surely there must be a way that we can make wiser choices about the health care we provide. In 2010, medical providers were challenged by Dr. Howard Brody, writing in the New England Journal of Medicine, to do their part to reign in the costs of health care. He implored physicians to come up with lists of the top 5 ways to reduce costs in their field, by reducing the ordering of unnecessary and potentially harmful tests and procedures.
This campaign became known as the Choosing Wisely initiative. All primary care and specialty societies were called upon to create their “top 5” list of things to not do. The items on these lists had to be commonly performed, not usually needed, potentially harmful, and have a substantial impact on cost savings for the patient, the medical system, and society as a whole. In an almost unprecedented response, nearly every medical specialty in the United States came up with an evidence-based list of ways to reduce cost and reduce harms within their field.
The Choosing Wisely campaign, a national movement promoted not just by medical and surgical societies, but also by multiple patient advocacy groups, is further unique in that it encourages physicians and patients to have conversations to determine if certain tests or procedures are truly indicated. Patients are encouraged and empowered to ask their health provider if they really need a particular test or procedure, if there are less expensive options, if there are simpler or safer options, and what would happen with not doing anything at all.
As an example of what these “top 5″ lists look like, the following is a list from the American Academy of Family Physicians:
- Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
- Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
- Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
- Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
- Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks gestational age.
Having created these lists, incorporating them into everyday practice is the next challenge for all physicians and their health care colleagues. Providers need to know the top 5 list for their own specialty, and apply these principles in daily interactions with patients. Fortunately, the Choosing Wisely website, www.choosingwisely.org, is a rich resource on which all participating specialties and their recommendations are listed, along with the medical evidence behind them. There are also handouts for physicians to give to patients on many of the recommendations.
In Family Medicine, when seeing a patient with acute uncomplicated low back pain or a mild respiratory illness, it can be tempting to just order an xray or prescribe antibiotics. These may be the easy thing to do and the quick thing to do, but they are not always the right thing to do. Unnecessary lumbar xrays increase costs without improving outcomes, while exposing patients to needless radiation. Most sinusitis seen in primary care is viral. Antibiotics in these cases are ineffective, can cause immediate side-effects, and overuse can result in future antibiotic resistance. This unfortunately results in antibiotics not working when they are needed most. It is hard to have conversations with patients and explain why they don’t need what they maybe thought they did, and to take the time to do this well in busy medical clinics. Some providers worry that patients will leave unhappy and unsatisfied without getting certain tests or treatments. But if we can discuss the rationale for this well, patients will understand that inaction, rather than action, is sometimes the best medical care. This is what we must do, even when it is difficult.
The Choosing Wisely campaign is a powerful tool that we can use to improve the lives of our patients. We must provide safe, appropriate, and cost-effective care in Family Medicine, as well as in every specialty. We must all uphold our oath to ‘first, do no harm’. We must now allow this oath to encompass considerations not just of our patients’ physical and emotional health, but their financial health as well. When we all do this well, when this becomes the new culture of medicine, then we will deliver lower-cost care at a higher-quality than ever before, as has been shown to us to be possible by so many other developed countries.
Kirsten Stoesser, MD is an Assistant Professor at the University of Utah Family Medicine Residency.