The Choosing Wisely campaign sought to prompt physician–patient conversations about unnecessary care. At its 2012 launch, physicians and patients felt uncomfortable about “denying” even unnecessary or potentially harmful care. Opponents of the Affordable Care Act raised fears of rationing and death panels. Physicians and patients had long mistrusted the motives of third parties, including employers, health plans, and government. Physicians feared that policies designed to reduce cost would impair their autonomy and patient care.
Addressing overuse, then, would require overcoming the problem of dual agency, where physicians are perceived as putting the financial interests of others above their patients’ interests. This problem has plagued other attempts to reduce unnecessary care, such as the managed care experiments of the 1980s and 1990s, which created a backlash from the public and many physicians who mistrusted the motivations of health plans and the physicians working with them.
Serving two masters–conflicts of interest in academic medicine.
This paper explains how Choosing Wisely addressed dual agency and what it teaches us about building trustworthiness, potentially instructive lessons as physicians and delivery systems enter financial risk arrangements that could jeopardize patient trust. Although trust in “the medical system” remains relatively high, it has declined more rapidly than any segment Gallup has measured over the last 50 years, falling from 80% in 1975 to 37% in 2017.
Trust in individual physicians remains respectable, with 65% of Americans rating the honesty and ethical standards of physicians as “very high” or “high”; however, the United States ranked 24th
of 29 nations in how many patients agreed that “All things considered, doctors in the U.S. can be trusted.”
Choosing Wisely's design attempted to overcome patients’ and physicians’ suspicions. First, it focused on the patient–physician relationship, promoting conversations that focused on optimizing health and preventing harm. To reduce “background noise” from actors outside the clinical relationship, we partnered with specialty societies and consumer and employer groups, not health plans. Consumer Reports created resources like patient-friendly explanations of clinical recommendations and wallet cards with 5 questions to ask physicians. The societies’ involvement provided physicians with a trusted source of recommendations, while also normalizing speaking to patients about overuse.
A Physician Charter created in 2001 by the American Board of Internal Medicine Foundation (ABIMF), the American College of Physicians, and the European Federation of Internal Medicine served as an ethical foundation for the campaign.
ABIM FoundationAmerican College of PhysiciansEuropean Federation of Internal Medicine
The Physician Charter.
The Charter sought to define medical professionalism for the modern era, and included a social justice principle that featured a commitment to stewardship and prudent management of resources. ABIMF appealed to specialty societies through this concept of physicians’ professional responsibility to their patients and the communities they served to lead in identifying overused tests and procedures. Thus, the Charter was an antidote to dual agency and gave physicians the ethical basis for having such conversations. We sought to appeal to physicians’ intrinsic motivation, relying on physicians’ own motivation to do the right thing and avoiding the “dual agency” problem.
Several studies suggest that Choosing Wisely helped physicians discuss overuse. One found that 75% of physicians in a large medical group felt more comfortable discussing unnecessary care with their patients due to the campaign.
- Colla CH
- Kinsella EA
- Morden NE
- Meyers DJ
- Rosenthal MB
- Sequist TD
Physician perceptions of Choosing Wisely and drivers of overuse.
A national survey funded by the ABIMF found that 92% of physicians familiar with Choosing Wisely thought it was “very valuable” (49%) or “somewhat valuable” (43%) in helping them talk to patients about overuse.
Major systems such as the Henry Ford Health System, Duke University Health System, and the Los Angeles County Department of Health demonstrated their belief in Choosing Wisely's value by making campaign patient materials available in waiting and examination rooms, inviting conversations.
Promoting trust through conversation anchored in core professional obligations—an approach that perhaps represents an underutilized policy lever—was at the heart of Choosing Wisely's efforts to solve the dual agency problem. The campaign offers a number of other lessons in building trust. For example, ABIMF relied on trust to build a still-increasing network of participating specialty societies, growing from 9 in 2012 to more than 80 today. Societies were initially hesitant to participate, expressing concern about the potential reaction of their members and the public to their identifying overused tests and procedures, and about their members’ fears of malpractice liability and lost revenue.
Getting away from “absolutes” and respecting the need for clinical judgement was an important trust builder. Most Choosing Wisely recommendations do not focus on “never events,” recognizing the complexity of clinical medicine and not lending themselves to payment prohibitions.
The campaign engaged specialty societies by respecting their expertise and competence—an important attribute of trust—by allowing them to choose their methodologies for developing recommendations. We asked societies to follow 4 simple rules: recommendations need to be within your discipline; they need to be consequential, addressing things done frequently or that are costly; they need to be evidence based; and the development process needs to be transparent. This allowed them to work within existing structures and norms and built trusting relationships between the ABIMF and the medical and surgical communities. ABIMF appreciated the societies’ contributions and exhibited a nonjudgmental attitude by accepting their expertise and not designing an independent review step to assess their recommendations’ quality.
This trust in the specialty societies enabled the development of more than 500 recommendations. The campaign has been criticized for including some less robust recommendations
- Morden NE
- Colla CH
- Sequist TD
- Rosenthal MB
Choosing wisely–the politics and economics of labeling low-value services.
and, in a small number of cases, the authors concur. We consciously sacrificed having the most aggressive possible recommendations to obtain clinician trust and engagement. Still, the campaign includes many recommendations that address areas with high levels of overuse and high costs.
- Admon AJ
- Gupta A
- Williams M
- et al.
Appraising the evidence supporting Choosing Wisely® recommendations.
Trust always has a reciprocal element. Evidence of trust among our partners has not been measured directly, but it can be imputed by the 23 societies that have developed more than the initial 5 recommendations required to join; 5 societies have issued more than 10.
In an effort to engage delivery system partners, the campaign operates learning networks that disseminate information about implementation, engendering trust among multiple organizations. Through a Robert Wood Johnson Foundation grant, we worked to spread the campaign through implementation by delivery systems, regional health improvement collaboratives, state medical societies, and specialty societies. In this project and other efforts, competing delivery systems have shared their lessons learned: a true example of collaboration and trust.
Choosing Wisely offers an important example of building trust through aligning values, respecting competence, and creating reliable relationships. It shows a path to address the perception and reality of dual agency, which is essential to meaningful reform.
Published online: December 17, 2018
Conflict of Interest: None.
Authorship: Both authors had access to the data and a role in writing this manuscript.
© 2018 Elsevier Inc. All rights reserved.