Choosing Wisely – suggestions for getting the right healthcare

Being a self-pay patient is about more than just finding a doctor, hospital, or other medical provider that will give you a real price instead of some inflated price that nobody but the uninsured pay. It’s also about getting the right medical care and avoiding unnecessary or ineffective treatments that waste money.

But how do non-medical professionals evaluate the value and effectiveness of the care we receive, or that is proposed? In a lot of cases, it may not be that hard to evaluate – if you feel better after the treatment, and continue to feel better, it was probably the right treatment.

That’s how I judge the effectiveness of my chiropractor, for example – a few months ago after building a bench for my son (a project that took nearly the entire 4-day 4th of July break – it’s a pretty big bench!) my back was killing me. After not having had to visit my chiropractor for a year, I went a couple of times for adjustments, and presto! Back’s all good again (and as a cash-pay patient, I pay less than what she would charge an insurance company).  

But it’s not always that simple. Fortunately there are many more resources today for self-pay patients (and anyone else too) that can give them some helpful information in terms of what their doctor might recommend for treatment options. One that came to my attention today is a site called Choosing Wisely. The site describes itself this way:

Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

In response to this challenge, national organizations representing medical specialists have been asked to “choose wisely” by identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting lists of “Five Things Physicians and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments.

This concept was originally conceived and piloted by the National Physicians Alliance, which, through an ABIM Foundation Putting the Charter into Practice grant, created a set of three lists of specific steps physicians in internal medicine, family medicine and pediatrics could take in their practices to promote the more effective use of health care resources. These lists were first published in Archives of Internal Medicine. 

Recognizing that patients need better information about what care they truly need to have these conversations with their physicians, Consumer Reports is developing patient-friendly materials and is working with consumer groups to disseminate them widely.

Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.

There are about 30 medical specialty societies that have put together a list of common treatments that may in many situations not be necessary. A brief sampling of their suggestions include:

American Academy of Pediatrics

1 Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).

Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.

3 Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.

Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.

Computed tomography (CT) scans are not necessary in the routine evaluation of abdominal pain.

American Academy of Family Physicians

Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

2 Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

3 Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

4 Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

5 Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

6 Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.

Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.

Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.

Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.

10 Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.

You can find all the recommendations on the Choosing Wisely – Lists page, which also includes several links to patient resources on a variety of topics, including Choosing a Pain Reliever: What to do if you have kidney disease or heart problemsEKG’s and exercise stress tests: when you need them for heart disease – and when you don’t; and Treating migraine headaches: some drugs should rarely be used.

One thing to keep in mind when reviewing the recommendations offered by Choosing Wisely is that they generally are based on studies of how, on average, entire populations that were studied responded to any given treatment. As my friends and associates who are medical professionals never tire of pointing out to me when it comes to so-called ‘evidence based medicine,’ they treat patients, not populations.

This simply means that there are very few ‘average’ patients, we all have our own unique medical complexities, and just because something doesn’t work for most patients doesn’t mean it won’t work for some (and conversely, just because a particular treatment works for most people don’t mean it will work for everyone).

To cite just one example of how individual patients react differently to any given treatment, the patient resource I linked above for migraine sufferers regarding drugs that should be rarely used, put together by the American Academy of Neurology (AAN), may indeed provide good advice for most patients.

But my wife suffers from severe migraines, and as a result I know the drugs recommended by AAN simply don’t work for her, while the drugs they suggest people avoid do work for her. So each individual patient is different, and ‘evidence based medicine’ isn’t necessarily the best treatment for all patients.

Probably the best resource I’m aware of on the shortcomings of ‘evidence based medicine’ is the site Citizens’ Council for Health Freedom, run by Twila Brase. You can find the information here: CCHF on evidence based medicine.

Choosing Wisely does say that they only offer general guidelines intended to spur discussion between patient and physicians, not hard-and-fast rules. If your doctor recommends something that this site or any other suggests hasn’t been shown to be effective for most patients, don’t assume they’re trying to put one over on you, just ask them why that particular treatment and not others has been suggested, and then listen to your doctor. Because ultimately we have to trust that they have the knowledge and the skill to make these sorts of decisions – if you don’t trust your doctor’s judgment, then you probably need to find another doctor!

Being a smart self-pay patient involves making informed decisions about what treatment is necessary and effective. Sites like Choosing Wisely can be a valuable source of information, and are worth a look.

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