Last week, nine physician specialty societies announced a list of 45 treatments and tests that doctors should prescribe far less often or stop doing entirely. Each specialty society’s list is part of the American Board of Internal Medicine’s Choosing Wisely campaign, a long overdue initiative intended to get physicians to think twice before giving patients tests, drugs and other treatments that aren’t going to help the doctor diagnose the problem or help the patient get better. What’s surprising is it took nearly a week for the anti-Obama forces to come out of the woodwork and claim that this laudable campaign is a thinly veiled attempt to ration care. One over-the-top blog went so far as to say that the Choosing Wisely campaign “repudiates the Hippocratic Oath.”
Let’s get real. The list is mostly stuff that most doctors already know isn’t going to help the patient, such as antibiotics for a cold or a mild sinus infection. Most upper respiratory infections are caused by viruses, and will clear up on their own in a few days. Yet about half of the 100 million prescriptions written for antibiotics each year are for respiratory ailments that aren’t going to be helped by a drug.
Prescribing an antibiotic for a viral infection is not only wasteful, it can hurt the patient. More than 140,000 people, many of them young children, land in the emergency room each year with a serious reaction to an antibiotic. Nearly 9,000 of those patients have to be hospitalized.
So why do doctors write the prescription? Most do it out of habit or to make their patients happy. A mother brings her sick child to the pediatrician and expects to walk out with a prescription. It takes time for the doctor to explain why antibiotics won’t do any good and might in fact do her child harm.
Most of the tests and treatments on the Choosing Wisely list are similarly low-hanging fruit, practices that most doctors already know they shouldn’t be doing. The vast majority of MRIs for uncomplicated low back pain, for example, won’t help the diagnosis and won’t change the course of treatment. However, they will bring in revenue for the hospital or the doctor practice that owns the MRI machine. Equally useless (and remunerative) are CTs or MRIs for the vast majority of headaches, and cardiac imaging for patients without cardiac symptoms.
A few items on the list aren’t so obvious. For example, the kidney specialists recommended that doctors not start a kidney-failure patient on long-term dialysis unless the patient is well-informed and really wants to begin the treatment. Cancer doctors are discouraged from prescribing curative cancer treatment to patients where there’s no reason to think it will work.
The fear-mongering from anti-Obamacare zealots was inevitable. They will raise the rationing flag at any effort to rein in our out-of-control health care system. Despite their rhetoric, the Choosing Wisely campaign is a huge step forward for patients. A year ago, the idea that nine medical specialties would say, “We’re giving our patients treatment they don’t need, and it’s time to stop,” would have been laughable. Today, the problem has hit the public consciousness rapidly, and not a moment too soon.
There is one reason to worry. Dozens and dozens of other ineffective and potentially harmful treatments have yet to be put on such a list, but when they are, the backlash could be ferocious. Treatments like vertebroplasty for back pain, and Avastin for breast cancer, have backers who will swear up and down that the treatment saved their life, even though there’s evidence it makes no difference. The critical choice that the specialty societies will have to make is whether they will fold in the face of the inevitable cries of rationing, or stand up for a rational health care system.