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A Word From the President: Will We Choose Wisely?

AAMC Reporter: October 2013

A few weeks ago at an AAMC governance meeting, I moderated a discussion on a subject that is on everyone’s mind today—the cost of health care. Specifically, how do academic medical centers, as the nation’s leading health care institutions, assure high quality and drive continued innovation in health care, while being mindful of the need to provide care as cost-effectively as possible? This is a question with no easy answer.

As we train the next generation of physicians and other health care providers, our medical schools and teaching hospitals have an important role to play. The first step is to acknowledge that we must confront this problem now, because, as Molly Cooke, M.D., observed in an opinion piece for the New England Journal of Medicine (2010), “Our country is remarkably generative in the development of new diagnostic tests, drugs, and procedures—and remarkably undisciplined in their deployment.” The net result is our national paradox of high spending combined with lagging health outcomes.

Perhaps even more remarkable is that only 36 percent of physicians see themselves as having major responsibility for the rising cost of health care, according to a study in the Journal of the American Medical Association this year. Instead, the majority of individual physicians pointed to trial lawyers, health insurance companies, hospitals, and even patients as having the most responsibility to reduce health care costs.

Creating a new culture of cost-awareness may require us to reach beyond our current roles. Today’s physicians need to be better informed about the broader impact of every decision made in patient care. In a health system strained by overspending, it is increasingly important for physicians not only to understand the evidence supporting different diagnostic and treatment options, but also to have a sense of the relative costs, including to patients, of those options. This is especially true as we encourage patients to ask questions and participate in shared high-value clinical decision making.

To promote this issue, the ABIM Foundation has developed an innovative campaign called Choosing Wisely®. The initiative is designed to eliminate unnecessary tests and procedures by promoting thoughtful discussions between doctors and patients. The plan starts with a basic checklist for any test, procedure, prescription, or other care being considered for a patient. The physician should ask if it is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.

This approach acts as a catalyst, reminding physicians to be responsible stewards of health care resources. The intent is to make physicians consider if they are adding value to a patient’s care by prescribing a particular test or procedure. The approach also offers a framework for physicians to have informed conversations with engaged patients.

Dozens of medical specialty societies are enhancing the Choosing Wisely effort by producing specialty-specific lists of evidence-based guidelines that address particular areas where unnecessary testing and procedures are common. For example, before an MRI is ordered for low back pain, did the patient try bed rest and pain medications? When is routine pre-operative testing truly necessary before a low-risk surgical procedure? While some doctors may not agree on some of their specialty recommendations, and others, such as emergency room physicians, are faced with implementing guidelines across multiple specialties, for the most part, patient groups and physicians have endorsed this approach to determining value.

There are many ways academic medicine can contribute to this important effort. First and foremost, we must communicate the vital lessons of responsible, wise choices throughout our organizations. We heard many terrific and creative ideas at our governance meeting in September that could be implemented at institutions nationwide. Learning modules directed at the hidden curriculum in which cost and value concerns are considered alongside the traditional medical content could be created for medical students. Administrators and faculty can be encouraged to share successful examples of costeffective care. Incentives can be used to reward people who achieve positive, cost-effective outcomes. We also heard how some institutions are engendering greater cost-awareness simply by having medical teams and students review patients’ medical bills to help them better understand the costs.

As leaders of the health care system, we have an obligation to promote more efficient use of health care resources. The Choosing Wisely campaign is making great strides in achieving this goal. The AAMC looks forward to working with the ABIM Foundation and the many specialty societies engaged in this effort, as well as helping our members implement a comprehensive series of evidence-based teaching and practice strategies that take cost and quality of care into account.

Health care has a new value equation in this country. We must provide our patients with the high-quality and safe care they expect and deserve. At the same time, we must remember our professional obligation to be good stewards of public resources. Achieving this balance will require a paradigm shift for health care providers, educators, and consumers. Will we all choose wisely?

Darrell G. Kirch, M.D.

AAMC President and CEO