The Less-is-More Approach to Health Care

Rachel Pomerance

There may be one less colonoscopy in your future.

You can thank the Choosing Wisely campaign, a massive effort by the American Board of Internal Medicine (ABIM) Foundation to promote the judicious use of health care resources amid increasing reports of wasteful health-care spending. As a result, the number of medical tests worth having are continually being called into question.

With the campaign's launch last year, the ABIM, in partnership with Consumer Reports, announced that nine medical specialties had each released a list of "five things physicians and patients should question." So, for example, the American Academy of Allergy, Asthma & Immunology advised against antibiotics for routine sinus infections, which are rarely caused by bacteria and usually clear up within two weeks. The American College of Cardiology said the use of annual stress tests in asymptomatic patients doesn't help and can hurt--leading to invasive procedures and radiation exposure.

Last month, 17 more specialties joined the cause. The American Society of Nephrology advised against the use of nonsteroidal anti-inflammatory drugs like aspirin and ibuprofen in those with chronic kidney disease, for whom such drugs can hike blood pressure, reduce kidney function, and cause other problems. Women between the ages of 30 and 65 don't need annual pap smears, announced the American College of Obstetricians and Gynecologists. And, according to the American Academy of Pediatrics, children should not have routine CT scans for abdominal pain, noting that the "increased lifetime risk for cancer due to excess radiation exposure is of special concern given the acute sensitivity of children's organs." More than a dozen specialties are slated to release their lists later this year.

The tipping point can be traced to a medical ethicist named Howard Brody, says Christine Cassel, president and CEO of the ABIM and ABIM Foundation and a physician who specializes in geriatric medicine.

Three years ago, in an effort to advance health care reform, Brody threw down the gauntlet. In an article for the New England Journal of Medicine, he challenged the medical profession to look closely at cost-cutting measures that would value patients over profit and, meanwhile, reign in excess amid spiralling health care costs. (Last fall, in a report entitled "Best Care at Lower Cost," the Institute of Medicine found that 30 percent of American health-care costs, or $750 billion, was squandered in 2009 on needless tests and services, administrative excess, fraud, and other failures that new technologies can help redress.)

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"The best rebuttal to the antireform argument that all efforts to control medical costs amount to the 'government getting between you and your doctor' is to have physicians, not 'government,' take the lead in identifying the waste to be eliminated," wrote Brody, who directs the Institute for the Medical Humanities at the University of Texas Medical Branch. He proposed the following solution: Each medical specialty should identify the top five tests and procedures that ought to be questioned--those that are common, expensive, and have shown no real benefit to large numbers of patients.

To explore this idea, the ABIM funded a pilot program by the Washington, D.C.-based National Physician Alliance, which enlisted doctors in internal medicine, family medicine, and pediatrics to determine a "top 5" list for each practice. Those results, published in 2010 in the Journal of the American Medical Association, spurred the campaign's creation, and, voila. By year's end, Choosing Wisely will boast more than 200 medical measures that should require rethinking. "The ultimate goal is to have doctors and patients be able to have a conversation about patient-centered care," Cassel says. Ideally, she envisions patients and doctors visiting the website together to determine which tests, if any, are needed. "Reducing waste is not rationing. It's, in fact, better for patients," she says.

That's a point underscored by Michael LeFevre, professor and vice chair of the University of Missouri's department of family and community medicine and co-chair of the U.S. Preventive Services Task Force, which issues recommendations on testing for preventive health.

"All medical care has harm," LeFevre says, noting the risks inherent in any procedure or medication, which may cause adverse reactions including death.

On a macro level, the widespread provision of antibiotics has led to crises surrounding the evolution of drug-resistant bacteria and consequent calls for conservative use by the U.S. Centers for Disease Control and Prevention and others.

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"Physicians have the same ethical obligation to avoid unnecessary care as we do to provide necessary care," LeFevre says. But the less-is-more sensibility does not yet inform American medicine, he explains. "Nobody ever comes in in the morning and criticizes their attending because they ordered too much stuff."

That's due in part to the fee-for-service system, which rewards doctors for ordering tests, and also fears of malpractice. But the system is beginning to change, said Cassel, who hopes that the new standards will serve to protect doctors from lawsuits.

But what about the patients? Will these recommendations against various tests stand in the way of their particular care?

"Every individual deserves a precise and unique approach, so anytime you have a blanket policy, that's not a good thing. But for the most part, these things have strong evidence that they're not helping people," says Eric Topol, a cardiologist at San Diego-based Scripps Health and author of The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. "It doesn't say anywhere, 'don't do for anyone.'"

Furthermore, the campaign's effort to empower the consumer marks much-needed progress, he says. "That's a first. There was never the voice of the patient. It was always the doctor, doctor, doctor," he says.

While Topol applauds the campaign, he stresses that much more needs to happen to effect these changes. Everyone ought to have these recommendations at their fingertips--literally programmed into their smartphones, he says.

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Already, health care systems such as Kaiser Permanente, are helping promote the campaign, Cassel says, noting that Choosing Wisely recently received a $2.5 million grant for continued regional outreach from the Robert Wood Johnson Foundation, which funds public health programs. "The message is not so much 'Never do this' as it is 'Let's talk about this,'" says Susan Mende, senior program officer of the RWJF. "Choosing Wisely provides a platform for providers and patients to have conversations about avoiding unnecessary care and changing the paradigm from more care is always better care to the right care is better care."