It is Our Choice…
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC I am rarely dogmatic, but I implore our Academy membership to visit http://www.nejm.org/doi/full/10.1056/NEJMp1314965 and take 15 minutes to read an article from the New England Journal of Medicine about the Choosing Wisely campaign.1 The authors begin with a noble goal of elevating the status of the Choosing Wisely campaign in the Perspective column of the journal. In the introductory paragraphs, they accurately note how the campaign is different from other initiatives in that, “The message, the messenger, and the method are key features of this stewardship initiative.”1 The Choosing Wisely campaign has been embraced and applauded by medical societies as it asks providers to define those services that are low-value services, “emphasizing individual patients’ needs as the top priority, preserving the preeminence of physician judgment, patient choice, and the therapeutic dyad. Doctors and their societies, not payers, develop the lists.”1 Unfortunately, the article continues with the theme that by empowering physicians and our respective societies to create a list of low-value services, that we as practitioners are inherently self-serving and have political motives driven by a desire to optimize our own reimbursement. Aided by Academy member Richard M. Rosenfeld, MD, MPH, and our EVP and CEO, David R. Nielsen, MD, we immediately wrote a letter to the editor at the New England Journal of Medicine. Whether this is published or not is beyond the point; what is imperative is that Academy members understand that we interpreted and responded to the Choosing Wisely campaign as we were instructed. The goal of Choosing Wisely is to aid patients in interpreting medical advice and to curb overutilization of those services that physicians and societies consider as low-value. As such, many societies provided examples of low-value services that broadly influence a significant number of patients. The authors inaccurately assert that these societies listed their low-value services to preserve our own economic interests while directing attention to other specialties. This is quite a perverse argument that is not justified by data, rather by simply showing the lists of the societies and claiming that they were created by self-interested societies. It is unfortunate and obvious that the authors did not seek out an opportunity to speak with or read our explanation from the societies to understand our methodology, which has been documented.2 The article calls out the American Academy of Orthopaedic Surgeons and other societies, including ours: “The American Academy of Otolaryngology—Head and Neck Surgery, for example, lists three imaging tests and two uses of antibiotics but no procedures, despite decades of literature on wide variation and overuse of tonsillectomy and tympanostomy tube placement.”1 The inherent conflict with this assertion juxtaposed to the rest of their article is frustrating—our Academy approached the Choosing Wisely list in a democratic manner, asking the various subspecialties to identify low-value services that they see and experience with their patients. Indeed, if we had focused solely on procedures that are low-value services, then we would not have the largest influence that we believe we can by looking at antibiotic and radiologic overuse—items that influence various disciplines of providers—family practitioners, internists, emergency physicians, pediatricians, etc. We anticipate in further versions of the Choosing Wisely campaign we will use our guidelines and other evidence-based medicine to identify such low-value services. I am going to make an unfounded assertion that is simply a personal observance—we all think that some other society besides our own—generalists’ or specialists’—are part of the problem of overuse. Hence, we are quick to assert that such “calling the other out” was motivated by economic self-interest rather than what it is—an attempt to genuinely help patients on a broad level. I applaud our executive leadership and Boards of the Academy for leading the surgical specialties in the Choosing Wisely campaign; we are fortunate to continue to be national leaders in improving the care of our patients and we eagerly look forward to participating in this unique endeavor to identify more opportunities for healthcare as a whole to influence the broadest proportion of patients—one low-value service at a time. We encourage members to write us with any topic of interest and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice. References Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—The Politics and Economics of Labeling Low-Value Services. N Engl J Med. 2014 Feb13;370(7):589-592. Robertson PJ, Brereton JM, Roberson DW, Shah RK, Nielsen DR. Choosing Wisely: our list. Otolaryngol Head Neck Surg. 2013 Apr;148(4):534-6.
Rahul K. Shah, MD
George Washington University School
of Medicine
Children’s National Medical Center, Washington, DC
Unfortunately, the article continues with the theme that by empowering physicians and our respective societies to create a list of low-value services, that we as practitioners are inherently self-serving and have political motives driven by a desire to optimize our own reimbursement. Aided by Academy member Richard M. Rosenfeld, MD, MPH, and our EVP and CEO, David R. Nielsen, MD, we immediately wrote a letter to the editor at the New England Journal of Medicine. Whether this is published or not is beyond the point; what is imperative is that Academy members understand that we interpreted and responded to the Choosing Wisely campaign as we were instructed. The goal of Choosing Wisely is to aid patients in interpreting medical advice and to curb overutilization of those services that physicians and societies consider as low-value. As such, many societies provided examples of low-value services that broadly influence a significant number of patients. The authors inaccurately assert that these societies listed their low-value services to preserve our own economic interests while directing attention to other specialties. This is quite a perverse argument that is not justified by data, rather by simply showing the lists of the societies and claiming that they were created by self-interested societies.
It is unfortunate and obvious that the authors did not seek out an opportunity to speak with or read our explanation from the societies to understand our methodology, which has been documented.2 The article calls out the American Academy of Orthopaedic Surgeons and other societies, including ours: “The American Academy of Otolaryngology—Head and Neck Surgery, for example, lists three imaging tests and two uses of antibiotics but no procedures, despite decades of literature on wide variation and overuse of tonsillectomy and tympanostomy tube placement.”1 The inherent conflict with this assertion juxtaposed to the rest of their article is frustrating—our Academy approached the Choosing Wisely list in a democratic manner, asking the various subspecialties to identify low-value services that they see and experience with their patients.
Indeed, if we had focused solely on procedures that are low-value services, then we would not have the largest influence that we believe we can by looking at antibiotic and radiologic overuse—items that influence various disciplines of providers—family practitioners, internists, emergency physicians, pediatricians, etc. We anticipate in further versions of the Choosing Wisely campaign we will use our guidelines and other evidence-based medicine to identify such low-value services.
I am going to make an unfounded assertion that is simply a personal observance—we all think that some other society besides our own—generalists’ or specialists’—are part of the problem of overuse. Hence, we are quick to assert that such “calling the other out” was motivated by economic self-interest rather than what it is—an attempt to genuinely help patients on a broad level.
I applaud our executive leadership and Boards of the Academy for leading the surgical specialties in the Choosing Wisely campaign; we are fortunate to continue to be national leaders in improving the care of our patients and we eagerly look forward to participating in this unique endeavor to identify more opportunities for healthcare as a whole to influence the broadest proportion of patients—one low-value service at a time.
We encourage members to write us with any topic of interest and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
References
Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—The Politics and Economics of Labeling Low-Value Services. N Engl J Med. 2014 Feb13;370(7):589-592.
Robertson PJ, Brereton JM, Roberson DW, Shah RK, Nielsen DR. Choosing Wisely: our list.
Otolaryngol Head Neck Surg. 2013 Apr;148(4):534-6.