Jeffrey Kullgren, MD, MS, MPH, a general internist and researcher from VA’s Center for Clinical Management Research and the University of Michigan Medical School has a method for implementing Choosing Wisely® recommendations. He relies on a behavioral economics technique referred to as “precommitment” which, in this instance, calls upon physicians to make choices rooted in medical professionalism.is defined as “a decision or set of decisions taken in the present in order to limit the agent’s options in the future.” For people looking to lose weight, precommitment might include paying for a costly gym membership or weight loss program. By spending the money upfront, they are making an important decision to achieve their goal.
In this instance, Dr. Kullgren understands that physicians want to do the right thing for their patients, but a busy practice can sometimes interfere with this desire. His strategy involves approaching physicians about the campaign when they are away from their busy practice and asking them if they would be willing to commit in writing not to give a test or treatment for specific conditions per the Choosing Wisely recommendations.
The next time a patient presents with that condition—for example, sinusitis—the physician, prior to entering the exam room, is provided a copy of their written precommitment along with patient-friendly materials from Consumer Reports to give to their patient. Instead of acting in the frenzied moment of a commonly all-too-short patient visit, the physician, reminded of their precommitment, can recall their knowledge of the recommendation during the visit. Due in no small part to its simplicity and ability to be implemented on a large scale, this intervention is currently being evaluated under a grant from the Robert Wood Johnson Foundation for its effectiveness to reduce waste and its acceptability to physicians.
The reason this technique interests me is how it appeals to a physician’s sense of professionalism as articulated in the Physician Charter. It respects the autonomy, competence and mastery of the physician by enabling the physician to do the right thing and leaving the discretionary power in the hands of the physician. Physicians are committing to adhering to the recommendations on their own, rather than having them enforced by systemic influences.
Marketplace and regulatory forces have long been used to try to improve the performance of the health care industry; in particular, physicians’ performance, under the belief that if we give physicians more money, they will be more motivated to provide less care that is harmful to patients. We have treated physicians as “ knaves and pawns,” to quote the JAMA piece by Sachin H. Jain, MD, MBA and Christine K. Cassel, MD.
In their Health Affairs article, Gregory Pawlson and Margaret O’Kane wrote how regulation, marketplace forces and professionalism are needed to reinforce each other and foster professionalism. My question is: In what ways do our current methods to “motivate” physicians through financial gains and regulatory rules enforce professionalism? I would argue that, in fact, these methods detract from it. As I’ve written previously, these financial incentives yield mixed results at best.
The ABIM Foundation’s mission statement is “to advance professionalism to improve health care.” Dr. Kullgren’s intervention is an excellent example of this. Should this precommitment work to spread the word of Choosing Wisely, it may transform medicine in the future. Thank you, Dr. Kullgren, for leading the profession, payers, purchasers and the government down this new path.
Daniel B. Wolfson
EVP and COO, ABIM Foundation