patient safety

Less is More

Steven Peskin MD

On April 4, the American Board of Internal Medicine Foundation launched Choosing Wisely, a campaign to educate health care professionals and consumers about tests or procedures that should be questioned because of lack of evidence that they’re needed and/or because of evidence that says the tests or procedures should not be done in the context that is delineated. http://www.abimfoundation.org/.

The ABIMF did this in collaboration with nine medical professional societies — the American Academy of Allergy, Asthma & Immunology; the American Academy of Family Physicians; the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology. Consumer Reports is also involved with this campaign to reach a broad consumer audience.

This initiative marks an important milestone. Historically, most medical professional societies have advocated more, not less. Each of the nine organizations involved in Choosing Wisely is explicitly recommending that many commonly ordered tests and procedures that are routinely done in a particular situation not be routinely done. Three representative examples:

  • Don’t do imaging for uncomplicated headaches (American College of Radiology)
  • Don’t do screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary artery disease (American College of Physicians)
  • Do not repeat colorectal cancer screening (by any method) for 10 years after high quality colonoscopy is negative in average risk individuals (American Gastroenterological Association)

The mantra of “less is more” is one that has been largely overwhelmed by campaigns spouting that “more is better” when it comes to health care related testing and services. Think about the conventional lexicon as it relates to medical testing and procedures: “The doctor gave me....” or, “I was given….” Negative potential health consequences — for example the considerable radiation exposure with CT scanning — as well as cost consequences, are often underappreciated. Eight more medical professional societies have stated that they will join this campaign. Keep up the good, and much needed, work!

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the
University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

Find and Fill: Gaps in Care

Steven Peskin MD

So many gaps, so little time.... That would be a ready conclusion from the extensive body of literature on gaps in patient care, medical errors, and patient safety. A recently released in-depth report from the American Medical Association,  Research in Ambulatory Patient Safety, chronicles gaps related to diagnostic, laboratory, clinical knowledge, communication, and administrative (potential) errors. The possible combinations among these five domains is extensive. The report highlights the measurement activities of the Agency for Healthcare Research and Quality, CMS’s Physician Quality Reporting Initiative, the National Committee for Quality Assurance, the National Quality Forum, Meaningful Use Clinical Quality Measures, and the Joint Commission for Accreditation of Healthcare Organizations’ Patient Safety Goals. 

At the risk of oversimplification, it strikes me that two prescriptions for improvement would address the great majority of gaps. First, knowledge- or evidence-related gaps in diagnostic, laboratory, medication, and clinical integration could be substantially enhanced through clinical decision-support tools. The ease of use, the availability of a myriad of hardware options, and the choice of software and cloud-based configurations make this completely achievable. Physicians and other clinicians should not feel threatened by "Watson" but should embrace the power of artificial intelligence / peripheral brains to free up their neurons to take advantage of machines’ mastery of data retrieval and information integration. 

Second, reinvigorating and revitalizing health care encounters through patient/ clinician interactions that are thoughtful, with focused but unpressured conversation, will go a long way to address the remaining gaps and errors. Leaders in medical education, policy makers, and payers must work to see that these skills are taught, acknowledged and rewarded.

Steven R. Peskin, MD, MBA, FACP, is medical director of Horizon Healthcare Innovations, Horizon Blue Cross Blue Shield of New Jersey, and associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.