The Choosing Wisely campaign is at both very modern and very old-fashioned. Modern in that it embraces the reality of the patient as an internet-savvy consumer who is no longer totally dependent on the physician for information. But in many ways, Choosing Wisely still lives in the world of dear old Dr. Welby, but without the paternalism. Just as in most current bioethics writing itself, CW imagines a dyadic “doctor-patient relationship” which ignores all the realities of how the office is run, how care is influenced by billing, the problem of defensive medicine, and on and on.
When I had hip replacements some years ago, I realized that my most important relationship was not with my surgeon, but with his secretary. Sure, my surgeon was really great, but without knowing how to cut through office protocol and reach his secretary directly, my chances of talking to him on the phone or getting an appointment within six months, were close to zero. And in my experience with cataract surgery, described in the previous post, the problem was not the surgeon, but all the layers of office staff who refused to let me talk with him, and then whoever made policy at the surgery center. To an astonishing degree, given how powerful surgeons appear to us laypeople, my surgeon claimed to have no power over any of this (and therefore no ethical responsibility).
So one impediment to consumer use of CW is how difficult it is to get hold of one’s physician once one has left the office. Should one walk into each and every appointment with that specialty’s CW list clutched in one hand? Would that make one seem like the dreaded problem patient? At the very least, I think one should end every appointment with the question, “How can I speak with you (not your staff) if I have further questions,” and insist on a very explicit answer.
The CW website is full of great resources for physicians, including handouts for patients and communication modules that help physicians implement CW principles with patients. There are brief videos that demonstrate key elements of good communication, all within the context of avoiding unnecessary tests and treatment. But all the videos assume that it is the patient asking for the treatment, and the doctor who explains why it is unnecessary. We know that patients are often reluctant to ask about second opinions, for fear of offending the physician. It seems that it would be even more difficult for many people to question the doctor based on a list, even a list endorsed by the physician’s own medical society. So, how about some modules to support patients in talking with their physicians?