Traditionally, the main concern of the medical profession has been to preclude diagnostic errors, with a primary focus on the issues of underdiagnosis and undertreatment. Therefore, we have witnessed, particularly in the 20th century, the rapid development of laboratory medicine, imaging techniques, and therapeutic procedures. The number of available diagnostic tests and treatments has increased dramatically over the past 2 decades.1 In fact, the use of imaging studies has grown faster than that of any other physician service (Figure 1).1,2 It is estimated that in the United States overused or misused diagnostic tests cost approximately $210 billion annually (10% of health care costs).3
Growth in volume of physician services in the United States per Medicare beneficiary from 2000 to 2009
E&M—evaluation and management services.
Data from the Medicare Payment Advisory Commission.1
Sceptics have long warned us about the downside of too much medicine.4,5 A growing body of evidence suggests that the increasing numbers of medical tests and procedures drive up health care costs and, above all, can be harmful to patients. Even seemingly safe diagnostic modalities can be potentially harmful or even fatal if they lead to a cascade of additional unnecessary testing and invasive procedures with predictable complication rates.
But what to avoid?
For many years, we have had the benefit of practice guidelines issued by medical societies. However, these recommendations have tended to focus primarily on what procedures to follow, rather than on what tests and treatments to avoid. In an attempt to minimize medical resource overuse and to reduce the risk of harm, the American Board of Internal Medicine Foundation, along with Consumer Reports, partnered with 9 specialty societies to launch the Choosing Wisely campaign in the early spring of 2012.6 The societies joining the project included the American Academy of Allergy, Asthma and Immunology; the American Academy of Family Physicians (AAFP); the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology. These 9 organizations were asked to choose 5 tests or treatments that were prone to overuse within their areas of expertise. Consequently, a list of 45 tests and therapeutic procedures was announced on April 4, 20126; it has subsequently drawn widespread attention in the media.7,8 The most important items for each organization are presented in Table 1. Eight of the 9 societies listed at least 1 imaging-related test among their 5 items; in all, of 45 items, 24 specifically involved imaging techniques.
Most important items listed by each of the initial 9 organizations included in the Choosing Wisely campaign
Currently, the project brings together more than 40 organizations representing more than 600 000 members. In addition, some medical societies released a new (second or third) list in 2013. The list of partners and the complete inventories of the “Five Things Physicians and Patients Should Question” can be found at www.choosingwisely.org/doctor-patient-lists. Each “Five Things” list is the result of a long process within the organization, and each recommendation is accompanied by the reasoning and evidence for its selection.
Five Things and family medicine
The AAFP compiled its Five Things list in 2012 (Box 1).9 It is an endorsement of the 5 recommendations for family medicine previously proposed by the National Physicians Alliance and published in the Archives of Internal Medicine as part of its Less is More series.10 The rationale for the selection of each item on the list is presented on the Choosing Wisely website.9 The goal was to identify items common in primary care practice, strongly supported by the evidence and literature, that would lead to substantial health benefits, reduce risks and harm, and reduce costs. A working group was assembled for each of the 3 primary care specialties: family medicine, pediatrics, and internal medicine. The field testing with family physicians showed support for the final recommendations, the potential positive effect on quality and cost, and the ease with which the recommendations could be implemented.9 As part of an ongoing effort to help physicians curtail the practice of ordering unnecessary tests and procedures, the AAFP released its second Choosing Wisely list of recommendations on February 21, 2013, followed by a third list on September 24, 2013 (Box 1).9 The campaign underscores family physicians’ long-term commitment to ensuring high-quality, cost-effective care for patients. According to Dr Glen Stream, board chair of the AAFP,
The American Academy of Family Physicians is committed to the Choosing Wisely campaign and its mission of sharing evidence-based clinical information about tests and procedures to help family physicians and their patients make informed decisions. So much so that the AAFP has extended its involvement, developing a second list of five screenings and treatments that are frequently overused or misused.11
The initiative seeks to encourage physicians and patients to follow evidence-based recommendations in managing health problems, while avoiding medical tests and procedures that are unlikely to help. Physicians and patients must both understand that more care is not always better care; in some instances, it can bring more harm than good. This campaign promotes physician-patient dialogue about making wise choices for tests and procedures. These actions will also reduce the rapidly expanding costs of the health care system. The campaign seeks to inform the public that not every test and procedure is appropriate for a particular condition. These lists will also stimulate the debate about the right care, at the right time, for the right patient.
The campaign is reaching millions worldwide through the efforts of consumer partners led by Consumer Reports, the world’s largest independent product-testing organization,12 which has worked with the American Board of Internal Medicine Foundation and the specialty societies distributing patient-friendly resources that facilitate consumer conversations with physicians. The Choosing Wisely consumer partners include the following, among others: Alliance Health Networks, the National Business Coalition on Health, the National Partnership for Women and Families, Union Plus, and Wikipedia.13 Such lists will not only help patients stay informed about common diagnostic and therapeutic procedures but will also enable them to make wise treatment decisions.
List of commonly used tests and treatments to question compiled by the American Academy of Family Physicians
The original “Five Things Physicians and Patients Should Question” released in April 2012
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The second “Five Things Physicians and Patients Should Question” released in February 2013
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The third “Five Things Physicians and Patients Should Question” released in September 2013
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Data from the American Academy of Family Physicians.9
↵* Written in collaboration with the American College of Obstetricians and Gynecologists to develop the final language.
Limitations of the recommendations
As the list of medical services expands and becomes more widely implemented, the Choosing Wisely campaign will permit physicians to provide safe, effective, high-quality care with the additional benefit of lowering health care costs. By establishing these recommendations as standards of care, the societies reduce the risk that doing less might spur malpractice suits, which currently prompt many doctors to overtest and overtreat—so-called defensive medicine.14
The proposed recommendations could serve as a road map to help physicians and patients navigate a maze of diagnostic and therapeutic interventions. However, some experts express caution, warning that the recommendations could be misinterpreted and applied too broadly at the expense of patient health. Some say that the group’s advice might make tailoring care for the individual patient harder. Both medical professionals and patients need to be aware that the necessity of tests is a highly individual matter. We have to bear in mind that the choice of diagnostic and therapeutic modalities might not be the same for any 2 patients, even those with the same condition.
As this campaign is relatively new, it is too soon to tell whether it has reduced the use of tests and treatments itemized in the Five Things lists. At some point a rigorous evaluation of the methods used by the project will be needed. Future studies should spur conversation about what is appropriate and necessary treatment, and not whether these recommendations should be used to establish coverage decisions or exclusions.
Worldwide action
The Choosing Wisely campaign builds on the standards and ideas set by the Physician Charter,15 the Less is More series of the Archives of Internal Medicine,16,17 and the National Physicians Alliance.10 Recently, more institutions joined the effort to combat overmedicalization, producing the Avoiding Avoidable Care (http://avoidablecare.org) and Selling Sickness (http://sellingsickness.com) conferences, as well as the Preventing Overdiagnosis conference (www.preventingoverdiagnosis.net), of which BMJ was a partner.18
Although the Five Things project is prepared by American specialty societies, medical resource overuse is a problem in many countries around the world and needs international action. In Canada, a similar campaign called Choosing Wisely Canada (www.choosingwiselycanada.org) was launched on April 2, 2014.19Several societies took part in the initial wave, including the Canadian Cardiovascular Society, the Canadian Association of Radiologists, the Canadian Medical Association Forum on General and Family Practice Issues, the Canadian Orthopaedic Association, the Canadian Society of Internal Medicine, the Canadian Rheumatology Association, the Canadian Geriatrics Society, the Canadian Association of General Surgeons, and the College of Family Physicians of Canada, who are all interested in working collaboratively to move this forward. The Canadian Medical Association has the support of 30 medical societies, currently at various stages of engagement in the campaign.19
The hope is that all of these projects will prompt discussions among physicians, patients, consumer advocates, policy makers, and health care reformers about the appropriateness of many frequently ordered diagnostic tests and therapeutic interventions. What is more, all of these campaigns are important policy initiatives that could restore public trust in the medical profession.
Footnotes
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This article has been peer reviewed.
Cet article se trouve aussi en français à la page 884.
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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