Better care starts with dialogue: Society of Hospital Medicine

The Choosing Wisely campaign is about much-needed dialogue between physician and patient, says John Bulger, DO, MBA, chief quality officer, Geisinger Health System, Danville, Pa., and chair of the Choosing Wisely subcommittee of the Society of Hospital Medicine’s healthcare quality and patient safety committee. In years past, medicine was paternalistic, he says. “The physician ordered the test, the patient didn’t know what was going on.” That’s changing, though there’s still work to be done. “It’s a professional issue,” he says. “We ought to be having a discussion with the patient about what the tests are and what we should expect from them.”

Such discussions can benefit both patient and doctor, he continues. “As a physician, you may begin to think, ‘Why am I ordering this test? What will I do with the result? Will it change what I’m going to do management-wise?’ The result may be, you end up performing fewer tests. It’s a positive byproduct.” Further, that kind of discussion is in line with the hospital medicine movement, for which creating efficiency in hospitalized patients’ care has always been a hallmark, says Bulger.

The Society of Hospital Medicine has issued 10 Choosing Wisely recommendations – five for adult medicine, five for pediatric medicine, but because the hospitalist’s scope of practice is so broad, SHM members are affected by recommendations from a variety of other specialty societies, says Bulger. “There’s been a lot of buzz about our recommendations,” he adds, and SHM intends to heighten interest by sponsoring a contest that will reward those members with the best stories about implementing Choosing Wisely recommendations.

Implementing change in medical practice is a gradual process, says Bulger. The medical/legal issue – that is, the fear that if certain tests aren’t ordered, the physician could be held liable in court somewhere down the line – certainly plays a role. “But some of the strength of the Choosing Wisely campaign is that the recommendations are evidence-based; to some extent, they highlight what the standard of care should be,” he says. “That should help protect physicians from the medical/legal issue, though there hasn’t been a test of this yet.”

But some of the resistance to change comes from patients themselves, due in part to the lack of communication between patient and physician, says Bulger. It takes time and effort to discuss with the patient why he or she may not need a urinary catheter, transfusion, heart monitor or even antibiotics. “But those discussions can be pretty straightforward, and the patient is usually comfortable with the outcome,” he says.

SHM: Five Things Physicians and Patients Should Question

From Choosing Wisely, an initiative of the ABIM Foundation,

Adult hospital medicine

  1. Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically-ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for
  2. Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
  3. Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.
  4. Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
  5. Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

Pediatric hospital medicine

  1. Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis.
  2. Don’t routinely use bronchodilators in children with bronchiolitis.
  3. Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.
  4. Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy.
  5. Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.