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Recently, the American Board of Internal Medicine (ABIM) Foundation, working in conjunction with numerous medical specialty boards and Consumer Reports, instituted an initiative to decrease the number of medical tests ordered unnecessarily by physicians. It also has contributed to new recommendations for annual exams. The initiative is called “Choosing Wisely.” The following are some of the pros and cons of this initiative.
Pros:
Reduction in healthcare spending: An article appearing in Kaiser Health News reported that $6.8 billion dollars were spent in 2009 on twelve unnecessary tests and treatments, such as ordering routine blood work during yearly physicals on healthy patients, performing Pap smears on teens who were unlikely to have cervical cancer, and ordering drugs for children with sore throats that were caused by viruses. Some experts estimate that up to 1/3 of every health care dollar spent in the U.S. is wasted on unnecessary tests, treatments and medications. A McKinsey report states that “health care spending reached record levels in 2009, both in absolute terms and as a share of GDP” . Few people will disagree that we need to spend less money on healthcare and reduce waste where possible; therefore, cutting out unnecessary tests and treatments may be a good place to start.
Reducing the risk to patients: First, do no harm. Performing unnecessary medical tests or prescribing unnecessary treatments to patients could be potentially harmful. For example, performing an unnecessary x-ray exposes the patient to harmful radiation. Prescribing antibiotics that aren’t clearly indicated (i.e. for viral infections) could result in an unforeseen drug reaction or antibiotic resistance. In addition, ordering unnecessary tests and procedures may result in increased patient anxiety.
Cons:
Missing a diagnosis: One concern about discouraging tests is it might result in missing a diagnosis that otherwise may have been caught through routine testing. Some physicians may feel uncomfortable about the new initiative for this reason. A big part of the reason that physicians order multiple tests is due to the fact that doctors are vulnerable to being sued when they miss a diagnosis. Fear of litigation is a driving force behind physicians’ ordering practices. Until this fact changes (or the laws do) some doctors may be reluctant to Choose Wisely.
Removing autonomy: Some might argue that physicians go to school for many years and should be able to practice as they see fit. If insurers and payers determine that certain tests and treatments will not be reimbursable, this can be seen as a challenge to physicians’ autonomy and decision-making ability. Many doctors will be less than appreciative of this kind of oversight. On the patient side, such an initiative might not be met with favor by patients who have become used to certain treatments and test. These patients may also feel that money is being given a higher priority than their health.
As nurses, it will be our job to explain to patients why tests and treatments that they have grown accustomed to receiving are no longer being offered. Rather than confronting their physician, patients may choose to confront nurses instead. Researching “Choosing Wisely” can help us prepare for these questions.