I applaud the spirit, but remain skeptical

I just got back from a trip to Disney World (worth a post on its own), and found my mailbox full of clutter. Most of it had to do with the Supreme Court still, which I still think at this point is mostly mental masturbation. The decision has already been made. We can speculate all we want for the next two months, but I’ve got better things to do than play prognosticator. We can focus on all that in June.

I was, however, intrigued by news yesterday that Choosing Wisely had released their recommendations:

The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

Look, I’m all for this. I think it’s great. But it’s also important to have a little perspective. None of these recommendations were news to those of us who practice medicine and follow the literature. Seriously, try and find a physician who doesn’t know that overuse of antibiotics for sinusitis is a problem.

The real issue, as I’ve discussed before, isn’t that doctors don’t have access to evidence. You can say that mammograms should be used less often, but when enough physicians call that “crazy” and “unethical” and label the USPSTF “idiots”, then it’s all sort of moot.

Here’s another post worth reading. Do you think that if Choosing Wisely said tomorrow we should not use arthroscopic surgery for knee pain all of that would go away? Really? It hasn’t worked yet.

When I really think about it, I’m forced to admit my skepticism comes from a place of cynicism. I wish that wasn’t the case, but it is. Some doctors fear lawsuits; this won’t change that. Some doctors see a subset of patients that aren’t representative of the general population, and are conditioned to believe that more tests are necessary than really are. This won’t change. Some doctors are influenced by financial incentives that subtly or overtly induce them to do more. This won’t change that either.

Most of these efforts assume that we can change the behavior of physicians by willing them to do good. I wish that were true. If we really want to change behavior, we have to arm recommendations like these with teeth. Stop paying for stuff we know doesn’t work. Or, make people pay for it out of pocket. If we know something doesn’t work, there should be few people willing to defend using both reimbursement-limiting and consumer-directed means to reduce its use.

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