An Essay on Choosing Wisely in Medicine

DECEMBER 14, 2019
Simon Murray, MD
Simon MurrayThere is near unanimous consensus that many medical procedures, tests, and prescriptions given to patients are unnecessary, but there is some debate about what drives those decisions.

Doctors claim that patients demand antibiotics and threaten to leave the practice if they do not get them. They also report that patients request tests that may be unnecessary, and healthcare providers often acquiesce to these wishes because they do not have the time to fully explain why the test may be unnecessary.

There is no financial incentive not to do more tests, although testing is not without its inherent risks, which may factor into the decision. There is some reason to believe that many things done in medical practice are driven by malpractice fears. That’s probably true, although while I think the risk is overstated, it is considerable.

But it is fear, uncertainty, and a desire to avoid confrontation that may drive intuitive decision making.

The American Board of Internal Medicine and 9 other specialty organizations got together in 2012 to develop the Choose Wisely Program. This was part of a joint venture with Drexel University and part of a larger program to begin a dialogue between physicians and patients about what type of testing was necessary and what was not.

Each specialty organization came up with a list of 5 procedures for which there was high-level evidence to support the recommendation. They were written to be guidelines and not standards of care.

That is a very important distinction. A physician would be in legal jeopardy if they ignored standards of care in their communities. On the other hand, guidelines are written to be suggestions. They are written in a way that allows physicians more leeway in deciding whether to follow.

As we come to the end of the year, I thought it might be interesting to review what the guidelines are and how they can help patient care.

The program never really garnered much attention and I do not think it was appreciated for the genus of its simplicity. It was an attempt to change deep-seated physician behavior not with a hammer but with a velvet glove.

It avoided the heavy-handed language common to the federal government and was written in a way that did not make it easy for lawyers to use them inappropriately to pursue malpractice cases. Suggestions were composed carefully and based upon high-quality evidence written by experts and on scientific data.

The subject of physician thinking has been a topic much discussed, largely because it’s physicians who are the most influential in driving healthcare costs either directly or indirectly.

We are all influenced by our prior experience. We will never forget the case of finding a life-threatening disease that was picked up surreptitiously by a test or procedure ordered strictly on intuition. That great medical pickup is forever remembered while the hundreds of other times the test proves to be useless are long forgotten.

I think an interesting thing about physician thinking is the role that intuition plays in medical decision-making even without our knowledge. We often believe that our decisions are based on sound and logical scientific thinking.

A cruel twist of cognition is that the brain tricks us into believing that which we believe is true and which we have a fair understanding of. We reject that which we do not understand and do not know and often do not recognize how much bias influences our decision-making.

We also discount the role that chance and luck play in outcomes of many of our decisions. We certainly remember the dramatic successes and failures we have had at medical diagnosis, but do not remember or do not even know about the thousands of patient encounters where our diagnostic choices are unknown to us.

Intuition is influenced by what you remember from prior experience and emotional thinking. Euphoric recall or memories that are pleasurable play a more prominent role in intuitive thinking. Psychologists felt for some time that intuition was a function of intelligence but have more recently come to believe that intuition is simply a matter of recognizing patterns that have been repeated.

Operating by intuition allows us to make quick decisions or perform routine tasks like driving a car on a deserted street. It allows a baseball player to react quickly to a ball hit to the outfield without thinking about it. If he had to stop and think in detail about the arc that the ball takes after leaving the bat, how many feet it will travel per second, and the effect of gravity, it would be too late to act. But through years of experience, the outfielder has a sense of where to catch the ball because he’s done it successfully a thousand times before.

Intuitive thinking quickly tells you that an oak tree is larger than a tomato plant and that 2 + 2 = 4. Where intuitive thinking fails is in more complex situations like when trying to solve complex math problems, perform statistical analysis, or assess probability.

Intuitive thinking involves very little energy and we rely more on intuition rather than deep thinking when we can get away with it. Intuitive thinking is an adaptive mechanism applied when time is limited, when we are threatened or uncertain and must react quickly.

Logical thinking is slow. It involves analysis and building one thought upon another in a logical sequence, considering the risks and benefits and assessing the probability that our actions will be successful. We develop our intellectual thinking by what we learn from reading, listening, remaining curious, remaining active in social networks, and keeping physically fit. That’s the same advice I’ve heard psychologists give patients on how to prevent cognitive decline.

Over time, more of our thinking has become intuitive and less logical. The logical part of decision-making is time consuming and requires more energy. It certainly doesn’t fit well with the modern societal paradigm of learning from sound bites, Twitter, and a few lines flashed on an electric screen. We fail to recognize how many decisions we make illogically.

Anyone who walks into a gambling casino, puts a needle in his arm because it feels good, or has an affair is using intuitive thinking (remember intuition is based on recognizing patterns of behavior influenced by emotional thinking and euphoric recall). Those are the obvious examples, but most types of intuitive thinking are far less obvious.

So, when you consider some of the guidelines, try to get beyond your intuitive thinking and recognize that they were developed logically based upon a large amount of data. Do not be influenced by the one time you hit a home run by making a strictly emotional or intuitive decision.

I would encourage you to review the guidelines that are appropriate to your specialty and begin to have the discussion with patients on the things we do. It may take a little more time but will result in less prescriptions, less tests, and less cost for everyone.

The one caveat is that the only truth in nature is that there is no absolute truth. The truth is only what we believe to be true at this moment based on what we know now. Therefore, guidelines may change.

There is also no guarantee that following guidelines will prevent malpractice claims, although not following them may be used by a plaintiff’s lawyer against you. We are all working towards individualized, targeted therapies for patients and guidelines may not always apply to everyone, but at least knowing them may guide your logical thinking process.

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