A New Way to Improve the Doctor-Patient Conversation

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Choosing Wisely, a campaign developed by the charitable organization the American Board of Internal Medicine Foundation, aims to encourage conversation between clinicians and patients about which diagnostic tests and procedures are most appropriate in addressing patients' health concerns.

The initiative involves 70 national medical speciality societies, and the creation of lists of evidence-based recommendations on everything from antibiotics to magnetic resonance imaging (MRI). The ABIM Foundation has two lists compiling more than 400 recommendations on overused tests and treatments, one designed for clinicians and the other, a more patient-friendly resource.

Given its citation in a recently published article in the journal JAMA Internal Medicine, the campaign appears to be gaining momentum.

A study, conducted jointly by researchers from the University of California - Davis, Sacramento and University of Rochester, NY, investigated whether initiatives aimed at enhancing the bond between primary care physician and patient would decrease rates at which low-value tests were ordered.

In a Medscape article, lead study author, Dr. Joshua Fenton described "patient-centredness," or overall satisfaction, as the provision of healthcare that aligns with patients' wants, needs and goals.

The study included 60 second-year, internal-medicine and family-medicine residents at two clinics in California, with 31 of them forming the control group.

Two undercover instructors posed as patients, a male requesting an MRI for lower back pain, and a middle-aged female requesting bone mineral density (BMD) testing.

Recommendations on the use of both of these tests can be found on the Choose Wisely lists. At the end of the encounter, the 30 residents of the intervention group were critiqued by the "fake" patients, and given feedback on six patient-centered techniques that did not involve ordering the unnecessary test. The control group was not given face-to-face feedback, but were later emailed relevant clinical guidelines.

Up to three unannounced standardized patient (SP) clinic visits followed over a 3-to-12 month period, with unnecessary patient requests for spinal MRI, BMD scans, or headache neuroimaging. The results were as follows:

  • Residents ordered low-value tests in 41 SP encounters (26.5%) with no significant difference in the odds of test ordering in intervention residents relative to control group residents
  • Rates of test ordering among intervention and control resident groups were similar for all three SP cases
  • The SPs rated visit satisfaction higher among the intervention residents than the control residents (8.5 vs 7.8 percent)

The intervention did not work. But why?

With smartphones in the hands of persistent patients, who have immediate access to more medical information than ever, clinicians have become acutely aware of the consequences that could lie ahead when they say "no" to a patient's request for an inappropriate test or treatment. While some patients can be reasoned with, others prove more difficult, and getting the point across that a test may do more harm than good becomes an arduous task.

While a doctor's face-to-face recommendation may not suffice, the hope is that documents like the Choose Wisely lists can help to better reach patients.