Vten years ago an initiative was launched in the United States to encourage medical discussion about useless services. It’s called Choosing Wisely. For these talks, lists were drawn up of measures that the eighty professional societies involved considered unnecessary or even harmful based on the available evidence – such as treating children with uncomplicated infections of the upper respiratory tract with an antibiotic. Ten years later, Elizabeth J. Rourke of Brigham and Women’s Hospital in Boston is sobering. Rourke speaks as a practicing physician and instructor.
In Germany, there has been a similar initiative called “Klug Decisions” for seven years. Choosing Wisely needs to be rethought and reinvented, writes Rourke in the New England Journal of Medicine. It is not enough to just publish lists of recommendations and trust that they will encourage medical dialogue. Because the recommendations for political reasons should not be a steep template for the reduction of services, in the USA it is only about improving the medical discussion, not about eliminating services with little benefit. That turns the initiative into a toothless tiger because it cannot be proven whether a conversation took place.
Rourke also believes that the criticism raised from the outset has not been dispelled. The initiative was accused of the fact that many recommendations are at the expense of other specialists, relate to services that are hardly ever done anyway, and that nothing is on the lists that really harm the doctors financially. Rourke’s conclusion is clear: “Choosing Wisely has allowed physicians and medical societies to pretend they are taking action against services of little benefit without actually being forced to change anything of substance.”
“Anyone who does practical medicine sees that the abuses continue”
What does this criticism mean for the German initiative, which is supported by the German Society for Internal Medicine (DGIM)? Unlike in the USA, the focus in Germany is not on improving the medical consultation, but on improving the quality of the indication. Accordingly, there should be a legitimate and evidence-based reason for the diagnosis or therapy. That is why positive and negative recommendations are published in Germany – so far 165 in number. “We have now reached a point where it no longer makes sense to primarily publish more recommendations,” says Sebastian Schellong, Medical Director of the Dresden City Hospital and Chairman of the DGIM Consensus Commission for formulating the recommendations. “We now have to take care of the implementation.” Schellong and his colleagues are therefore planning a survey. “We are interested in whether the colleagues implement the recommendations. And if not, what is preventing them and which measures are most plausible to them so that implementation can progress,” says Schellong. “Anyone who does practical medicine sees that the abuses continue.”
The vascular physician locates the difficulties in implementation in the contradictory interests of the driving forces. The doctors don’t want to do anything wrong, the patients want to be treated in the best possible way, and the false incentives in the healthcare system do not favor the doctor’s discussion, but procedures. “It’s about a culture change,” says Schellong. “Physicians must lose interest in pointless services. What we can do as a professional society is to take away their fear of the prosecutor, motivate them to stand by what they have learned in their training and encourage them to move their everyday lives away from the quick procedures and towards something more change conversations.”
How can this culture change be brought about? The DGIM focuses primarily on student teaching and works with popular teaching platforms. “We are seeing a change in attitude among many young colleagues who are switching from their studies to specialist training,” says Schellong, “but we also need political decision-making to eliminate the false incentives in the healthcare system.” In Germany, there is still no ten-year balance sheet but the German initiative is still a long way from reaching its goal.