Emergency Physicians – Please Choose Wisely

August 19, 2019 4:21 PM | Sally Winkelman (Administrator)

WACEP President's Message
Jeff Pothof, MD, FACEP

I must admit, I'm one of those people who often thinks bigger is better.  if a 60-watt light bulb is good, then the 100-watt bulb must be better.  I'd be completely content with the three-piece fish fry, but the all you can eat is only $2 more and the batter is so thin and crispy.  I won’t even get into what happened the last time I bought a truck, but I think you have a pretty good idea.

This type of thinking often follows us into the emergency department.  More is better.  It must be true.  It makes me feel better, re-assured.  It seems to make my patients feel better too.  What could be the harm in a more is better approach to patient care?

When reports came out from the Institute of Medicine in 20001 and 20012 characterizing healthcare as unsafe and describing the strategy for improving the performance of our healthcare systems an era of measurement was born.  We started measuring, with the assistance of the electronic health record, we measured everything. 

We had data on nearly anything we did with accompanying graphs in full color, benchmarks, control charts, goals, and incentive plans to match.  Therein was the problem, we measured what we did.  We inadvertently and with the assistance of fear from our tort system and lack of consequence from our reimbursement models fueled physicians into practicing with a more is better philosophy. 

Unfortunately for our patients more is not always better.  More recently we have begun to look at the things we do in medicine that perhaps we should not have done.  In 2012 the Choosing Wisely3 campaign was launched and challenged medical specialties to identify those things commonly done but were shown to have no meaningful benefit to patients.  Instead of thinking about quality of care delivered defined by what providers did, they instead looked at quality of care defined by what providers didn’t do.  Choosing Wisely is now in it’s seventh year.  Many of you have no doubt heard about it and ACEP with help from emergency physicians like you and I have developed our own list of 10 things we shouldn’t be doing that we commonly still do. Please take a moment to look at the list.4 

Were there any surprises?  I think many of us at one time or another have done some of the things in that list.  Even conceding that individual patient factors sometimes makes doing these things necessary there are still times where I know I’ve done some of the things on that list.  Often time the act of doing is easier than the act of taking the time to adequately explain why we are not doing something.  Sometimes just the idea of the conflict that awaits us as we attempt to do the right thing is enough to make us hit the sign button on an order.

Although not what I look forward to most on a shift, I think part of being a physician is having those difficult conversations where we hold ourselves accountable to doing the right thing, often with the patient and family understanding the decision making and appreciating the time it took to paint the picture for them, but sometimes having to place safe and quality care over patient preference and expectations.  More so today than in the past I also worry about not only how my decisions to order something might affect the quality of care delivered, but what type of financial burden I may be putting on my patients and their families.  It used to be more out of mind for me.  Most of my patients had insurance and my perception was that cost wasn’t a big part of the equation.  I don’t know about you but more and more of my patients either don’t have insurance or have insurance that really isn’t insurance with deductibles that are 10 times the amount of money they currently have in their savings account.  This makes me even more vigilant about those things that I might do that likely have no meaningful benefit to my patients as the harm may not be in the small radiation exposure, but instead in having them miss their rent payment or fail to fill a prescription.

I encourage all of you to be intentional not only about those things that are important for you to do to ensure you are delivering safe and high-quality care to your patients, but also the things you do not do to ensure you are delivering safe and high-quality care. Both are equally important.  Choose Wisely Wisconsin emergency physicians.

References:

  1. Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press
  2. Committee on Quality Health Care in America, Institute of Medicine.Crossing The Quality Chasm: a New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001
  3. Choosing Wisely: http://www.choosingwisely.org/
  4. http://www.choosingwisely.org/wp-content/uploads/2015/02/ACEP-Choosing-Wisely-List.pdf