Choosing Wisely ® Campaign by ABIM Foundation Reviewed.

The American Board of Internal Medicine (ABIM) Foundation has started a new Choosing Wisely ® campaign that asks doctors and patients alike to question the value of some testing thought to be costly, perhaps harmful and not medically necessary based on prevailing evidence. This is a campaign who's time has come.  It is in fact how Happy practices every day.  The first and most important question he asks himself every day is, "How will this test change my management?"  If the answer is it won't, then the test is deemed medically unnecessary by Happy's standards.  Nine medical specialty societies were asked to submit five things patients and doctors should question in their daily medical decision making.  The medical societies  included in this initial effort were:
  • American Academy of Allergy, Asthma & Immunology
  • American Academy of Family Physicians
  • American College of Cardiology
  • American College of Physicians
  • American College of Radiology
  • American Gastroenterological Association
  • American Society of Clinical Oncology
  • American Society of Nephrology
  • American Society of Nuclear Cardiology
A total of 45 recommendations were submitted for the Choosing Wisely ®  campaign.  What were my three favorite worthless recommendations we should be choosing wisely?
  1. American Society of Clinical Oncology: Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment. 
    • This recommendation is worthless because it is loaded with subjective adjectives that no physician and patient could possible quantify or define and will change based on the weather outside, whether the doctors' kids have soccer practice this afternoon and whether the doctor had a fight with their spouse the night before.  No benefit?  Clinical value?  The problem with this recommendation is it reads like an editorial and is loaded with personal bias.  Every physician and every patient is going to have a different opinion on the matter, thus making the recommendation irrelevant for mass consumption and application in everyday life.
  1. American College of Cardiology:  Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
    • I disagree with this one completely.  The ACC has basically tied the hands of their  cardiologists behind their backs.  It's a travesty, I say.  And they call themselves a cardiology association.  Now, without echo, cardiologists are no more helpful than gastroenterologists who document a murmur on their history and physical.   Now how are the cardiologists  supposed to leave their yearly recommendations for the primary care physician if they don't do a yearly echo in all their asymptomatic valve patients?  Everyone knows cardiac auscultation is difficult and unreliable, especially after one or more years out of fellowship and  especially when you have a brand new  echocardiography machine in every patient's room just waiting to be paid for.
  1. American Gastroenterological Association: For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms. 
    • Come on, really?  How are we supposed to implement this into clinical practice?   Everyone knows that patients with chronic abdominal pain always come in with the worst pain of their lives and it is always much worse than normal.  The standard 12/10 pain always applies.     Besides, it was my partner who saw the patient last week and I know his physical exam skills are rotten.  So who am I to say there isn't a change in clinical findings?  The lawyer?  Right.  I'm not falling for that one.  Again.    Oh yeah, one other thing.  I've never been to ROME and I hear those Italians are really crackin' down on tax evaders driving fancy cars, so I don't plan on visiting anytime soon nor do I plan on using their suspect ROME criteria.  ROME wasn't built in a day and neither was this recommendation.  It took a lot of effort to give us this garbage recommendation.
Please don't misunderstand me.    Mixed in the 45 recommendations are some excellent clinical nuggets to discuss.  Unfortunately, not all of them can be applied with regular reliability in a clinical systematic process, even with our built in clinical EHR decision tools.   In a fast paced, volume driven, model of care that is America defined,  the variables involved in these three medical decision trees will preferentially land on the path of least resistance, which for doctors, is the easiest answer (more testing) and for patients, the most satisfying, even if it isn't the safest, best or cheapest.  Try telling a dying cancer patient's husband  that their wife isn't worthy of more chemo, even if she hasn't been out of bed for 3 months.  Everyone knows the reason they aren't out of bed is because they need more chemo to shrink the tumor causing them their weakness.   It's a no brainer.

As a hospitalist and member of  the fastest growing medical specialty in America, I was disappointed to learn of the absence of hospitalist recommendations from the list of offerings.  Perhaps my society will offer up their choice of rationing with the next installment of  Choosing Wisely ® 2.0.   I'm giving you the next best thing.  I'm tired of waiting, so I've decided to offer Happy's Hospitalist recommendations for Choosing Wisely ® that every hospitalist should implement in their daily practice.
  1. If you don't want to find something wrong, then don't look for it.  And don't ask other consultants to look for it either.  Just leave  the patient alone.  The more you find, the less likely the patient is to like you, the worse your patient satisfaction scores will be and everyone will end up losing.  Just treat their UTI and let them go back to their nursing home with the little dignity they have left.  If I find out you ordered an echo on that severely demented 92 year old grandma that the  nurses aide at the nursing home said she heard diminished breath sounds on, so help me God, I'm going to report you to adult protective services.  
  2. Any FULL CODE patient that looks like they aren't going to survive CPR should get a stat palliative care consult.  You know who these patients are.  Quit fooling yourself.  Since you are a hospitalist and you are the one who shows up to watch the horror unfold, you owe it to your patient and family to get palliative care involved as soon as the patient is admitted.  That means if you need a stat pall consult to avoid the ICU end of life palliative care  travesty, so be it.  You wake up your pall doctor and you tell them you have an urgent 3 am consult for them to discuss code status in a 93 year old non English speaking Catholic Hispanic grandma with 22 children and 78 grandchildren hovering in the ICU room watching  their matriarch herniate from a massive brainstem infarct while the hospitalist prepares the team for code blue.
  3. Even if the patient looks like they would survive a code, my experience tells me most patients, once they understand that CPR is not a glamorous fun filled adrenaline rushed experience will decide they don't want to live out their remaining days, weeks or months confined to a nursing home bed enjoying the smell of pureed peas and incontinent stool with every breath.  That's what hospitals are for.  In these situations, the palliative consult can wait until the morning to discuss code status in a fully informed manner.
  4. If the patient has at least one chronic medical condition and has been admitted to the hospital at least two times in the last 90 days, obtain a palliative care consult.  Something ain't right.  I call it  Disease Stress Factor (DSF).  Hospitals are great places to treat acute illness that requires close monitoring.  Things like drug overdoses after unintentional suicide attempts, flash pulmonary edema from weekend cocaine binges and severe pancreatitis from acute alcohol intoxication are great uses of hospital resources. This is where hospitals shine.  Hospitals were never intended to cure chronic disease  or to be long term management options for recurrent decompensated chronic disease.  By nature, chronic disease is not fixable.    I define 2 admissions within  90 days to be a highly sensitive screening parameter for a high level of  DSF.  If your patient's DSF is high, make sure you take full advantage of your  palliative care team to help you define your goals as a hospitalist.  See recommendations #1, #2 and #3 for the next plan of action.
  5. Hospitalists who are asked to provide a preoperative evaluation history and physical for  cataract surgery should refuse.  This service is medically unnecessary.   There is no ICD code for history and physical.   Make sure you let the patient know that their insurance may not pay for your evaluation as you are going to document that the request was not medically necessary and  that you charge $400 to provide this service, cash up front and, when the patient refuses your evaluation, make sure you document your finding in the chart so the requesting physician can stay compliant with any necessary paperwork they must complete in accordance with hospital bylaws.
The Society of Hospital Medicine (SHM) recommendations should be released in the near future.   Any questions?

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