Choosing Wisely .
Even before the inception of the NHS, the British tradition has generally been one of late adoption and cautious use of new medicines, procedures, and technologies. Nevertheless, the UK shows similar patterns of variation in use of medical and surgical interventions to those in the US, though less extreme in absolute terms.
The National Institute for Health and Care Excellence (NICE) was set up in 1999 in part to address these unwarranted variations in clinical practice and has identified over 800 clinical interventions for potential disinvestment.
However, engaging clinicians with stopping familiar or ingrained practices requires a different approach to that for introducing new treatments.

An initiative recently developed in the US and Canada called Choosing Wisely (www.choosingwisely.org) aims to change doctors’ practice to align with best practice by getting them to stop using various interventions that are not supported by evidence, free from harm, and truly necessary, including those that duplicate tests or procedures already received.

Choosing Wisely asks medical organisations (such as medical royal colleges in the UK) to identify tests or procedures commonly used in their specialty, the necessity of which should be questioned and discussed. These are compiled into lists, and the “top five” interventions for each specialty should not be used routinely or at all. So far, more than 60 US specialist societies have joined in the Choosing Wisely initiative.
It has also been adopted by other countries, including Australia, Germany, Italy, Japan, Netherlands, and Switzerland—a clear sign that wasteful medical practices are a problem for all health systems.

The Academy of Medical Royal Colleges, which represents all medical royal colleges in the UK, is launching a Choosing Wisely programme in collaboration with other clinical, patient, and healthcare organisations.
Participating organisations will work together to develop top five lists of tests or interventions with questionable value.
The academy, royal colleges, and partners, including The BMJ, will then promote dissemination of this information and Choosing Wisely conversations between clinicians and patients.
These new conversations will rebalance discussions about the risks and benefits of tests and interventions, such that doctors and patients will be supported to acknowledge that a minor potential benefit may not outweigh potential harm, the minimal evidence base, and substantial financial expense and therefore that, sometimes, doing nothing might be the favourable option.

Tackling the underlying causes of overtreatment
A culture of “more is better,” where the onus is on doctors to “do something” at each consultation has bred unbalanced decision making.
This has resulted in patients sometimes being offered treatments that have only minor benefit and minimal evidence despite the potential for substantial harm and expense. This culture threatens the sustainability of high quality healthcare and stems from defensive medicine, patient pressures, biased reporting in medical journals, commercial conflicts of interest, and a lack of understanding of health statistics and risk.

The system has no incentive to restrict doctors’ activity; the NHS in England has a system of payment by results, which in reality is often a payment by activity and encourages providers to do more both in primary and secondary care.
General practice is increasingly pressured to focus less on open dialogue with patients about treatment options and more on fulfilling the demands and poorly informed expectations of patients.

The quality measures in both primary and secondary care are based on guidelines produced by NICE, in UK, but doctors should not consider these as tramlines because decisions need to be made with reference to individual patient circumstances, the wishes of the patient, clinical expertise, and available resources.
Some people would choose to take a hypothetical pill with no side effects daily, even for a few weeks’ gain in life expectancy, whereas others would prefer not to, even if they were told it would add 10 years to their lifespan.

We suggest that guideline committees should increasingly turn their efforts towards the production of tools that help clinicians to understand and share decisions on the basis of best evidence.
Rather than prespecifying the outcome of such dialogue, and trying to get medicine “just right,” they should try to ensure that decisions are based on the best match between what is known about the benefits and harms of each intervention and the goals and preferences of each patient.

More informed decision making can also alleviate, perhaps disproportionate, fears for those patients who may not want treatment.
A recent study revealed that when patients were told the lack of prognostic benefit for angioplasty, only 46% elected to go ahead with the procedure versus 69% who were not explicitly given this information.
Responding to similar concerns about getting patients’ consent for elective coronary angioplasty in the UK, NHS England’s cardiology lead, Huon Gray, stated, “It is important that doctors are clear with their patients about this.”

It is easy to misunderstand health statistics, and doctors can find themselves needing to manage unrealistic expectations of patients who may find it difficult to obtain reliable information.
Communicating relative risks as opposed to absolute risk or numbers needed to treat can often unintentionally mislead. As Gerd Gigerenzer, director of Harding Centre for Risk Literacy in Berlin, summarised in 2009, “It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks, to protect patients against unnecessary anxiety and manipulation.

Doctors’ health illiteracy is well documented.
Misunderstanding of statistics often leads to a belief that screening is more beneficial than it actually is and, in some cases, to no acknowledgment of its potential harms.
In a study of 150 gynaecologists, one third did not understand the meaning of a 25% risk reduction from mammography. Many believed that if all women were screened 25% of women (or 250 fewer out of every 1000) would die of breast cancer, when actually the best evidence based estimate is actually one less death per 2000 women (from Cochrane’s analysis of randomised studies including 500?000 women).

Both medical and surgical overtreatment can place patients at high risk of adverse events.
Shared decision making can help to reduce this over treatment and may be particularly beneficial to disadvantaged groups, significantly improving health outcomes and reducing health inequalities.

G Mohan.