Choosing Elephantoplasty Wisely

On April 4, 2012, American Board of Internal Medicine (ABIM) together with 9 other leading physician societies launched the Choosing Wisely^® program, which they describe as, “an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.” By signing on as a member society, each of these physician groups has identified lists of “Five Things Physicians and Patients Should Question.”  These lists are intended to “provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.”

What Choosing Wisely has done, in effect, is provide physicians and patients a list of 45 procedures and tests that they should either avoid or at least question before prescribing (in the case of doctors) or accepting (in the case of patients).  In other words, this is a large (over 357,000) cadre of physicians coming out and saying, “hey, maybe we are doing too many tests and procedures that have no clinical value and cost a lot of money.”  I have to tell you that I am a little worried about walking outside right now, as I might get hit in the head by an airborne pork product; if you had asked me when I thought doctors would start publicly cannibalizing their own revenue stream by outing their own overused procedures, I would have said, “When pigs fly.”

Among the things on the Choosing Wisely list are such questions as:

• Do patients need brain imaging scans like a computed tomography (CT) or magnetic resonance imaging (MRI) after fainting, also known as simple syncope? Probably not. Research has shown that, with no evidence of seizure or other neurologic symptoms during an exam, patient outcomes are not improved with brain imaging studies. (American College of Physicians)

• Do patients need stress imaging tests for annual checkups? Not if you are an otherwise healthy adult without cardiac symptoms. These tests rarely result in any meaningful change in patient management. (American College of Cardiology)

• Should patients going into outpatient surgery receive a chest x-ray beforehand? If the patient has an unremarkable history and physical exam, then no. Most of the time these images will not result in a change in management and has not been shown to improve patient outcomes. (American College of Radiology)

• Do patients need a CT scan or antibiotics for chronic sinusitis? Most acute rhinosinusitis resolves without treatment in two weeks and when uncomplicated is generally diagnosed clinically and does not require a sinus CT scan or other imaging. (American Academy of Allergy, Asthma & Immunology)

• Should dialysis patients who have limited life expectancies and no signs or symptoms of cancer get routine cancer screening tests? These tests do not improve survival in dialysis patients with limited life expectancies, and can cause false positives that might lead to harm, over treatment and unnecessary stress. (American Society of Nephrology)

It’s a very interesting list as it gets right to the heart of what insurers have been trying to do, with limited success, for a long time:  get doctors to be responsible by not over-using services that do nothing but increase costs.  In fact, the ABIM has come right out and said that one of the reasons they have created this initiative is that doctors are “better positioned to do this than insurance companies.”

That is undoubtedly true, but history has shown that it isn’t typical for doctors to voluntarily choose the path that makes them less money.   I am not trying to suggest that doctors aren’t ethical or responsible, but let’s be honest.  There is a long and esteemed history of many physicians providing unnecessary services that some believe make up as much as 30% of the healthcare systems overall costs. Doctors are not alone in their self-interest, to be sure.  For every doctor who has made ethically questionable decisions in the name of money there is also at least one lawyer doing the same thing and an abundance of venture capitalists who own the category.  But nevertheless, healthcare is where we have an economic disaster on our hands and it is nothing short of revolutionary for physicians to come out en masse and say, “Things we have gotten in the habit of doing perhaps do not always help the patient we are trying to serve,” as did Catherine Lucey, vice dean for education at the UCSF School of Medicine, chair of the ABIM and a trustee of the ABIM Foundation that has spearheaded the Choosing Wisely Initiative  (you can hear an hour long Michael Krasny/KQED interview with Dr. Lucey and others by clicking HERE).

In fact, in the very same week that the Choosing Wisely Initiative was launched, the American Clinical Laboratory Association (ACLA) published a study in Health Affairs demonstrating that, “…urologists involved in self-referral arrangements billed Medicare for 72% more specimens for patients with suspected prostate cancer than did urologists who referred specimens to independent providers of pathology services. This study suggests that men are at heightened risk of unnecessary and costly prostate cancer biopsies when under the care of a physician who benefits financially through self-referral. This is a serious unintended consequence of a legal loophole that needs to be corrected immediately by Congress,” said Alan Mertz, President of ACLA.

Go figure.  I guess the urologists haven’t signed on to Choosing Wisely just yet.

The whole discussion brought to mind one of my favorite medical comedy routines by Monty Python called Elephantoplasty.  In it Dr. Reg LeCrisp (Graham Chapman) discusses his most successful patient to date, the elephant /man named Mr. George Humphries.  The interviewer (John Cleese) says, “The surgery on Mr. Humpries is truly remarkable, but why an elephant?” and LeCrisp answers, ”Well, that was just a stroke of luck, really. An elephant’s trunk became available after a road accident, and Mr. Humphries happened to be walking past the hospital at the time.”  You can listen to the whole hilarious routine by clicking on the link below (after you click on the “Free Music” link below you have to click on the pink or blue arrow that appears on the album cover on the left..don’t worry, it’s short and free and funny!).

If you don’t feel like taking the two minutes to listen, you can just read the script of this Monty Python bit HERE.