Choosing wisely

Clinical decisions are often complex. There are many factors to take into account and many pressures within the health care context that pull us in different ways. Worryingly, there is increasing evidence of a general overuse of tests, interventions and procedures. In the United States as much as 20% of money spent in health care brings no benefit to patients. I spent the last week in Amsterdam at a “Choosing Wisely’ roundtable event which discussed how best to engage doctors with this important issue.

The “Choosing wisely’ initiative has had a big splash in the US and Canada and is inspiring clinicians to have robust discussions with patients about what interventions and tests are most helpful. The premise of ‘Choosing wisely’ is that overuse of tests and interventions is due to many factors but can be overcome by having new types of conversations with patients about the pros and cons of each option.

How can we ensure that we deliver the right intervention at the right time to the right person without overusing increasingly precious financial and environmental resource? The answer is of course multifactorial but I think that a good understanding of the cultural factors that influence doctors’ decision making would certainly be helpful. In addition to this, doctors should be aware of the clinical factors they should base their decisions on.

Cultural pressures that influence clinical decisions include defensive practices, clinical habits (“it’s the way we do things around here”), marketing forces from med-tech and big pharma, as well as looking good in front of seniors on a ward round. Commissioning structures that are based on activity rather than results also affect our clinical practices. If we are to fly in the face of these insidious pressures and ensure that we remain focused on providing interventions with the highest value for patients, what factors should we base our decisions on?

I believe a doctor needs to have a balanced view on four factors in order to make sustainable and ‘wise’ clinical decisions:

1. Patient benefit
2. Patient harm
3. Patient preference
4. Resource use

Currently, perhaps there is too much focus on the benefit that any intervention might achieve to the neglect of the other three factors. This unbalanced view is potentially leading to an overuse of clinical resource. Doctors have a difficult job weighing up many factors in each clinical decision they make, greater clarity about these factors would enable doctors to make more responsible and sustainable decisions.