The words we use to talk about the use of health care resources makes a difference in how we engage physicians, clinicians and patients in thoughtful discussion around the economic sustainability of the current health care system. These conversations must happen — without hysteria and political motivation. We need attitudinal and political changes before we can have behavioral changes.
The Institute of Medicine‘s “Crossing the Quality Chasm” refers to overuse as the provision of health care services for which the potential risks outweigh the potential benefits. According to IOM, underuse indicates a health care service for which the potential benefits outweigh the potential risks. Misuse “occurs when otherwise appropriate care is provided, but in a manner that does or could lead to avoidable complications.
Ari Hoffman, MD and Steve Pearson, MD, an expert in comparative effectiveness research, write about “marginal medicine.” Although I like their framework in examining medical decisions, I do not think the term “marginal medicine” will engage physicians or patients in meaningful conversations. Their framework depicts medical decisions where there is no clinical evidence, only evidence for a treatment working effectively and efficaciously within a subset of the population, and looks only at marginal effects of alternative treatments.
These definitions don’t provide me much comfort – they are about decisions that are not optimal – they are about the lack of quality decisions by physicians and sub-optimum decisions by patients about their care and their responsibility for their heath and medical care.
What we need to speak about is building a health care system that works for all Americans and gives everyone working in the health care system great pride and joy — not from a place full of quality, safety and cost problems caused by misaligned financial incentives and poorly designed delivery systems, but rather from a shared vision of what the performance of the health care system can and should be.
When we came up with the name for the ABIM Foundation’s Choosing Wisely campaign, we focused on the concept of the physician and patient choosing the optimal care for a particular diagnostic test or treatment and patient preference. “Provide me with all the care I need, no more and no less…the right care for me, at the right time, in the right way,” are the notions we wanted to express.
Choosing Wisely incorporates the notion of receiving care that has value and asks physicians and patients to speak openly together. It’s not just about language, it’s about the underlying pathway to solutions. We view the campaign as a pathway towards building more and better evidence, and better reliability of adherence to them and the skills to appropriately deviate from the normal course of treatment. It’s about systems and technologies that enhances that objective and do not distract from it.
Daniel B. Wolfson
EVP and COO, ABIM Foundation