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From: The Rheumatologist, March 2013

The ACR Releases Top 5 Things as Part of Choosing Wisely Campaign

by Audrey B. Uknis, MD

On February 21, the ACR--along with 16 other national medical societies--released its list of Five Things Patients and Physicians Should Question in Rheumatology. I want to tell you about why the ACR participated in this effort, organized by the ABIM Foundation as part of its Choosing Wisely campaign.

Healthcare Reform: Read All About It!

The national discussion and debate about U.S. healthcare reform is pervasive. It seems not a day goes by that the ACR’s Rheumatology Morning Wire doesn’t include a related story, as decisions made by lawmakers and others make headlines daily. Turn on any news program and you’ll hear more opinions than you even knew existed on the subject—political pundits demonizing the other party for their proposed solutions, or for failing to come up with a viable solution.

We hear about healthcare reform from our patients, too. Although they may, at one level, be concerned about our society’s ability to sustain current healthcare spending, as individuals, many are worried about continued access to the medical services and therapies that are vital to their well-being.

As physicians, we have a unique voice to bring to this national dialogue. We know our patients and their needs better than any other participant in this discussion besides the patients themselves. While others argue about increasing the value of goods and services received for each healthcare dollar spent, physicians and health professionals are best equipped to share what actually works—and what doesn’t—so these dollars can be wisely spent.

Physicians and Other Healthcare Providers Weigh In

In January 2010, Howard Brody, MD, challenged the physician community to identify, publicize, and implement lists in each specialty that would “consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered.”1 Dr. Brody asserted that organized medicine has an ethical responsibility to help ensure that healthcare dollars are used wisely so all patients have access to necessary and appropriate healthcare. He also encouraged physicians to consider that the autonomous relationship between patient and physician could best be preserved by ensuring that physicians—and not government or others—take the lead in identifying and eliminating waste.

Some organized physician groups had already begun this important work. The ABIM Foundation’s Putting the Charter into Practice program was launched in 2009 to provide small grants to advance principles of professional commitment in medicine, including “improving patient access to high-quality care, practicing evidence-based care, and advocating for just and cost-effective distribution of finite resources.”2

The National Physicians Alliance, the mission of which is to achieve affordable, high-quality healthcare for all patients, launched its Promoting Good Stewardship in Medicine project in 2009 with ABIM Foundation funding. The project’s goal was to identify five things primary care physicians could do in their daily practices to ensure high-quality, affordable care. The products of this work were three “Top 5” lists—for internal medicine, family medicine, and pediatrics—which were published in August 2011. The lists included some items of interest to rheumatologists, such as imaging for low back pain and DXA screening for osteoporosis.2

ABIM Foundation Choosing Wisely Campaign

The NPA Good Stewardship project served as the model for the ABIM Foundation’s ongoing Choosing Wisely campaign, which aims to promote conversations between physicians and patients by helping patients choose care that is evidence-based, not duplicative of other tests or procedures already received, not harmful, and truly necessary. Nine professional societies participated in Phase 1, including allergy and immunology, family practice, cardiology, internal medicine, radiology, gastroenterology, clinical oncology, nephrology, and nuclear medicine. Their efforts produced nine lists that were released in April 2012 to a flurry of national and local media coverage. The overwhelmingly positive coverage highlighted not only the 45 items to carefully consider, but also the engagement of physicians in these important value discussions.

ACR Involvement

The ACR decided in early 2012 to join Phase 2 of the Choosing Wisely campaign. ACR deliberations had already begun about how to best demonstrate and quantify value within rheumatology, and Choosing Wisely was a perfect opportunity to join our internal discussion with the national dialogue. Sixteen other organizations released lists in late February as part of Phase 2. In addition to the ACR, Phase 2 participants included hospice and palliative medicine, neurology, ophthalmology, otolaryngology–head and neck surgery, pediatrics, obstetrics and gynecology, geriatrics, clinical pathology, echocardiography, urology, cardiovascular computed tomography, hospital medicine, nuclear medicine and molecular imaging, thoracic surgery, vascular medicine, and family practice.

Rheumatology’s Five Things

The ACR developed its list with substantial input from the ACR membership and significant effort by several ACR members who volunteered to serve on the Top 5 Task Force. They were led by Dr. Jinoos Yazdany, of the University of California at San Francisco, and Dr. Charles King II, in private practice in Tupelo, Miss. The five things physicians and their patients should question in rheumatology include items related to treatment, imaging, and labs. More details about these items and the deliberations that led to their selection can be found at

Next Steps

The ACR will continue this dialogue with physicians and patients. In fact, development of a second list—for pediatric rheumatology—is underway and the list will be published later this year. We welcome ACR member feedback and active engagement on this issue at both the national and local levels. As rheumatologists and rheumatology health professionals, we play a unique and vital role in guiding patients toward the most effective rheumatology care. However, we also have a responsibility to be good stewards of the healthcare resources at our disposal. I encourage us all to preserve a healthy balance between these two goals in our daily practices to ensure that the most effective care continues to be available to the patients who need it.

Dr. Uknis is professor of medicine and senior associate dean for admissions and strategy at Temple University in Philadelphia. Contact her at


  1. Brody H. Medicine's ethical responsibility for health care reform—the Top Five list. N Engl J Med. 2010;362:283-285.
  2. Good Stewardship Working Group. The "top 5" lists in primary care: Meeting the responsibility of professionalism. Arch Intern Med. 2011;171:1385-1390.



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