In the information age, clinicians at busy clinics like United Community and Family Services (UCFS) in Norwich, CT, where Dr. Christopher Kolker practices family medicine, can be inundated with irrelevant data that gets in the way of making informed decisions about good patient care. That’s why Dr. Kolker has been an enthusiastic physician champion for Choosing Wisely at the federally qualified health center. UCFS Healthcare serves thousands of patients each year, providing primary care, dental care, women’s health and behavioral health services, and elder day care. Dr. Kolker discussed his experiences in addressing overuse with a diverse patient population:
What is unique about integrating Choosing Wisely into a FQHC?
At a FQHC (Federally Qualified Health Center), a team approach predominates in patient care. It is absolutely necessary that the entire care team (e.g. social worker, psychologist, and dentist) be involved with Choosing Wisely. It is easy for those who don’t know about the program to believe that more testing and more pills mean better patient care. By giving our staff the impetus and the legitimacy to focus on what is truly needed for quality patient care by asking if these tests, medications and procedures truly make a difference, we have found that we are able to cut to the core of the patients’ problems more effectively.
How did you bring Choosing Wisely to the entire system?
Since Choosing Wisely is a mindset of critical thinking for all health care providers and patients, buy-in by the physicians, nurse practitioners, RNS, LPNs and MAs is essential. We had several meetings explaining what Choosing Wisely is, where it came from, and why it needs to exist. The fact that it came from the ABIM Foundation was critical to our staff, who, like many in the medical field, tend to look at credentials as being highly important.
We then pointed to all of the redundant tests and medications, highlighting many of both that didn’t change decisions or outcomes. We also pointed out that empowering the patients to help decide and bringing them into the decision-making process can strengthen the provider-patient bond. And since Choosing Wisely is a cognitive initiative, this is not something that comes with a bureaucracy. That alone made it much more appealing to the staff. Subsequently, we hung Choosing Wisely banners to advertise to patients what we were trying to do and hoped to accomplish. The fact that the patients were included in Choosing Wisely really got them excited.
What has worked well in implementing Choosing Wisely in your setting?
With the initial rollout, having the buy-in before proceeding simply needed to occur. This had to be something that happened as a team with our providers, and not to our providers. Having an honest dialogue was the key. Many physicians were weary of practicing defensive medicine, with the stand-by answer of, “If I don’t do it, I’ll get sued.” Believe it or not, the posters and handbills for Choosing Wisely transformed the practice. As with most clinics, posters adorn our walls everywhere, warning of one disease or the other, admonishing the reader to either do or not do something. When starting the program, two Choosing Wisely posters were placed in prominent areas. Just two. Despite this, we received many more comments on these two posters than all of the others combined. Why? These posters encouraged patients to talk with providers about their treatment plan, to truly have a say. That was much more appealing than a poster that simply tells you what to do. Those posters started much of the dialogue we had with our patients.
What has been challenging in Implementing Choosing Wisely in your setting?
The initial buy-in for Choosing Wisely wasn’t 100%. Many of the older physicians felt uncomfortable with the concept for three main reasons: defensive medicine had become the norm, fear of time constraints, and a perception that less means poorer care. But we pointed out that Choosing Wisely doesn’t require anyone to stray from professional clinical guidelines. In fact, it asks practitioners to follow current guidelines. Many of the older physicians were surprised what was in the guidelines, and what wasn’t. We told them we wanted physicians to better engage patients about their care, and that simpler diagnostic and treatment patterns would mean less discussion of side effects, general feelings of malaise associated with overmedications, and that uncertain test results from unneeded tests would go down. Therefore the conversations and visits would not be longer; they would be different. That is exactly what came about. Patients liked the back-and-forth with the doctors, and really liked the more personalized critical thinking skills they got to see from their physician. Patient satisfaction grew.
What have you learned in implementing Choosing Wisely?
We learned more about patient thinking than anything else. Many thought that patients would think that we were trying to shortchange their care, and would be litigious in their thoughts and words. However, what really transpired is that patients want to be a part of the decision-making process of their own care. We found that many of our patients were very quick to learn the scenario at hand, and were quite insightful. They were highly intelligent, often to our surprise. They simply needed to be told in plain terms what specifically is going on and what the decision-making process is. What we learned about ourselves was a lesson in humility. We were not dealing with unintelligent people – in fact, many great points were made by our patients regarding their care. We found that we needed to ditch the condescending attitude that we often unconsciously had, and start to relate to our patients as equals. They may have expertise in a different area, but they could reason and think critically, just like we could.
What has surprised you in implementing Choosing Wisely?
I worried this would be time-consuming. I thought we may be inundated with frankly irrelevant and time consuming questions from patients. I believed many would simply want more tests and more pills. All of these presuppositions were incorrect. Choosing Wisely worked much better than I ever would have thought. And because of this, the practice of medicine at our facility is more insightful, and yet more based on national standards of care. Even when care differs from guidelines, that decision is based on a conversation with the patient, and is done for a good reason. The fact that everyone is critically thinking about what patient care should be is the most pleasant surprise of all.