The Challenge of Choosing Wisely

More than 60 medical societies and specialties now participate in the American Board of Internal Medicine initiative known as Choosing Wisely1. The initiative aims to stimulate conversation between patients and physicians about the appropriate use of diagnostic, medical, and surgical therapies.  The idea is to curb the overuse of interventions that are not evidence- based, or not high value (significant benefit, low cost).  Here are a few recommendations from the American Geriatrics Society: 

  1. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  2. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
  3. Don’t prescribe a medication without conducting a drug regimen review.

Having these conversations is easier said than done, particularly with older adults who may have sensory deficits, memory impairment, and/or multiple medical problems that take time to sort out and evaluate.  These patients may also be used to physicians directing their care rather than collaborating with them: “you’re the doctor, doc. Tell me what you think about another colonoscopy for me.” Physicians themselves may be patronizing with older adults, and less willing to offer options to these patients. And, of course, there is the time challenge: older adults need a physician’s time.  Having said that, building relationships and action plans through conversations with our patients:  what could be more important and rewarding than that?

Choosing Wisely: an initiative of the ABIM.     

–Dean Gianakos, MD, FACP

Dean Gianakos, MD, FACP, practices and teaches general internal medicine in the Lynchburg Family Medicine Residency and Geriatrics Fellowship, Lynchburg, VA.  He frequently writes and lectures on the patient-physician relationship, end-of-life care, and the medical humanities.