“The other thing I would point out is that CW also brings home the point that we shouldn’t be ordering unproven diagnostic tests,” says Dr. King. “We need to think about pretest probabilities and how a test will help diagnostically instead of just ticking off a box on a computer’s order list. Often, tests are ordered as screening tests instead of in response to clinical indicators.”
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Explore This IssueOctober 2014
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Rheumatology’s Strong Suit
If anything, the consensus of the experts is that the concept of Choosing Wisely leads to what has always been a strong suit of the rheumatologist.
“These all call for a good history and physical exam, which we are very adept at doing, as an entry point to proper patient management,” says Dr. Saag. “Taking a careful history and an appropriate physical examination that then leads to doing the simple things before moving on to the more expensive tests will provide needed answers at lower costs.”
As the healthcare system changes, there will be a growing focus on how and when the more expensive interventions are used. This is a continuation of Dr. Saag’s discussion of the change in emphasis from underutilization to overutilization.
“This is a way for societies to begin to police themselves and maybe stop doing things just because they are easy,” he says. “In an era of worry about the tremendous costs of healthcare, it is incumbent on us all to do the best we can for our patients, but also be aware of the costs.”
Impact on Clinical Decision Making?
Each time one of the CW lists is released, concerns have been voiced about taking away some of a physician’s ability to make decisions based on the patient they see in front of them. CW’s website stresses that the recommendations “are meant to spur conversation about what is appropriate and necessary treatment. As [sic] each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.”
“The recommendations made by each society’s CW list are meant to foster communication between patients and providers,” says Dr. King. “They are not meant to be proscriptive. Ultimately, the decision to order a certain test or treatment rests with the provider.”
There is also agreement that the healthcare system of the future is one in which physicians communicate with each other across multiple specialties and areas of expertise. This will require increasing cooperation and coordination around common areas in guidelines and clinical recommendations.