Choosing Wisely: Ten Years On, One PCP Urges That It Be Reworked

Since it was initiated ten years ago by the ABIM Foundation, the Choosing Wisely initiative has been held up as a model for how to engage practicing physicians in reconsidering their choices with regard to diagnostic tests and other elements, in order to help them avoid delivering “low-quality” care.

But, in a “Perspective” op-ed published online April 2 in The New England Journal of Medicine, Elizabeth J. Rourke, M.D., an internal medicine physician at Brigham & Women’s Hospital in Boston and an instructor at Harvard Medical School, argues that Choosing Wisely needs to be rebooted in order to be truly effective.

Dr. Rourke, in “Ten Years of Choosing Wisely to Reduce Low-Value Care,” argues that “Choosing Wisely” has proven largely ineffective, for a variety of reasons. As she notes at the outset, “Let me say at the outset that in my primary care clinic I practice low-value care. Not every day, but often enough. Probably every week. For example, when patients show up with a list of tests that need to be done before they can get their cataracts fixed, I do them. I want them to be able to see. Similarly, I’m well aware that imaging for acute, no-red-flag low-back pain is not recommended before 6 weeks, but there are times when I am unable to convince suffering patients to wait, and I order a lumbar spine plain film or MRI.”

As Rourke notes, “Both of these actions have been included on Choosing Wisely lists for primary care. For 10 years now, the American Board of Internal Medicine (ABIM) Foundation has been hosting the Choosing Wisely campaign, in which specialty societies create lists of items that “providers and patients should question.” The effort launched with lists from 9 societies and has since grown to include more than 80 societies and lists, comprising more than 600 items. In addition, the program has spread beyond U.S. borders to 25 other countries, including Canada, the United Kingdom, Germany, and Japan.”

Unfortunately, Rourke writes, though “Choosing Wisely was an immediate public relations win for the medical profession in 2012,” in reality, “In In retrospect, it seems obvious that merely labeling certain common practices as low-value was unlikely to result in their elimination. It’s worth noting that the stated goal of the Choosing Wisely campaign was not to reduce low-value care, but instead to promote professionalism in medicine and encourage conversations between doctors and patients. It’s part of the political genius of Choosing Wisely that these outcomes are not readily measured. Who can prove that conversations are happening? Who can quantify professionalism?”

And it is that looseness, Rourke says, that has led to a lack of real progress based on the Choosing Wisely guidelines. As she writes, “It’s frustrating to me that I often feel trapped between the actual circumstances of the patient before me and a theoretical determination by some remote, faceless entity that, for instance, MRI is not useful for acute, uncomplicated back pain. For patients whose physical agony is compounded by the fear of a life-threatening cause such as a tumor, who defines value? Is relief of anxiety worth the cost of an MRI? When? For whom? The realities of ‘value’ and ‘benefit’ on the ground are complex and fraught.”

Going through a number of weaknesses she perceives in the program, Rourke writes that, “In short, Choosing Wisely has allowed doctors (and medical societies) to look like they are addressing low-value care without actually being forced to make any substantive changes. The obstacles to meaningful reductions in low-value care are substantial. From an economic standpoint, health care is the tent pole of the American postindustrial service economy, and any significant reduction in the amount of care provided would result in financial and job losses.”

In the end, Rourke argues, “If Choosing Wisely is to continue, the specialty societies that have participated in it should celebrate its 10th anniversary by coming together to rethink and reinvent it.” Going through a rigorous process of re-envisioning its purpose and parameters could make the program useful in the future. And, she writes, “In this way, Choosing Wisely could make the transition from feel-good gesture and highly imperfect tool to catalyst for meaningful change in the postpandemic world.”