Physician groups each identify five of their own inappropriate practices

BMJ 2013; 346 doi: (Published 27 February 2013) Cite this as: BMJ 2013;346:f1266
  1. Miriam E Tucker
  1. 1Bethesda

Physicians from 17 specialty medical organizations have each produced lists of five common practices that are of questionable value, as part of a project to promote dialog with patients about appropriate use of tests, procedures, and medications.

The Choosing Wisely initiative ( was set up by the American Board of Internal Medicine Foundation, and 17 new lists were launched last week.

Each specialty society’s list is made up of common practices that are not supported by evidence, are not necessary, or may cause harm. The “five things physicians and patients should question” are written in simple language, including explanations for why the practice is not advised.

Antibiotic use is a major target, with advice against its routine use for acute sinusitis (from the American Academy of Family Physicians), adenoviral conjunctivitis (the American Academy of Ophthalmology), and acute external otitis (the American Academy of Otolaryngology).

Unnecessary imaging is another frequent theme. The American Academy of Neurology says, “Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.” And the Society for Vascular Medicine tells physicians: “Don’t re-image deep vein thrombosis in the absence of a clinical change.”

Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine cite practices that, although generally beneficial, are not appropriate in situations of limited life expectancy. Among these are “Don’t leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care,” and “Avoid using medications to achieve hemoglobin A1c less than 7.5% in most adults age 65 and older.”

This new set of lists is the second go-round for the Choosing Wisely initiative, which was first launched in April 2012, with nine specialty organizations issuing “Don’ts.” 1 Since then, those organizations have developed education materials based on their lists for their members and for patients. The widely read magazine Consumer Reports, AARP (formerly the American Association for Retired Persons), and Wikipedia have also joined in the effort to target the messages at the general public.

The ongoing initiative is expected to influence healthcare policy as well as practice.

Christine Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, said at a press briefing, “We’ve begun to stimulate a conversation about quality, safety, and patient centered care, along with reducing unnecessary tests and procedures.”

She said that Choosing Wisely “is about the right care at the right time for the right patient and changing the notion that more is always better.”

David Longworth, chair of the Cleveland Clinic’s Medicine Institute, said that his organization had already embedded the original “Don’t” lists into its clinical practice guidelines. “The drive to value for healthcare delivery in this country is a profoundly fundamental issue for our time, and we think this initiative supports that,” he said during a panel discussion.

Former Medicare director Gail Wilensky called Choosing Wisely “an enabler of change,” noting that it could help physicians by providing support against liability. She said that having the “Don’t” messages come from physician groups themselves rather than the government or private payers was far more likely to resonate with patients and the public.

However, she warned that the impact of the initiative might be limited until there was a greater shift away from payment systems that rewarded the exact behaviors it was trying to do away with. “We need to begin to pay on the basis of what we want to see provided, which is good clinical outcomes,” she said.

Another set of lists is planned for later in 2013, with an additional 12 specialty societies coming on board.


Cite this as: BMJ 2013;346:f1266