The Choosing Wisely campaign sought to prompt physician–patient conversations about unnecessary care. At its 2012 launch, physicians and patients felt uncomfortable about “denying” even unnecessary or potentially harmful care. Opponents of the Affordable Care Act raised fears of rationing and death panels. Physicians and patients had long mistrusted the motives of third parties, including employers, health plans, and government. Physicians feared that policies designed to reduce cost would impair their autonomy and patient care.
Addressing overuse, then, would require overcoming the problem of dual agency, where physicians are perceived as putting the financial interests of others above their patients’ interests. This problem has plagued other attempts to reduce unnecessary care, such as the managed care experiments of the 1980s and 1990s, which created a backlash from the public and many physicians who mistrusted the motivations of health plans and the physicians working with them.1
This paper explains how Choosing Wisely addressed dual agency and what it teaches us about building trustworthiness, potentially instructive lessons as physicians and delivery systems enter financial risk arrangements that could jeopardize patient trust. Although trust in “the medical system” remains relatively high, it has declined more rapidly than any segment Gallup has measured over the last 50 years, falling from 80% in 1975 to 37% in 2017.2 Trust in individual physicians remains respectable, with 65% of Americans rating the honesty and ethical standards of physicians as “very high” or “high”; however, the United States ranked 24th of 29 nations in how many patients agreed that “All things considered, doctors in the U.S. can be trusted.”
Choosing Wisely’s design attempted to overcome patients’ and physicians’ suspicions. First, it focused on the patient–physician relationship, promoting conversations that focused on optimizing health and preventing harm. To reduce “background noise” from actors outside the clinical relationship, we partnered with specialty societies and consumer and employer groups, not health plans. Consumer Reports created resources like patient-friendly explanations of clinical recommendations and wallet cards with 5 questions to ask physicians. The societies’ involvement provided physicians with a trusted source of recommendations, while also normalizing speaking to patients about overuse.
A Physician Charter created in 2001 by the American Board of Internal Medicine Foundation (ABIMF), the American College of Physicians, and the European Federation of Internal Medicine served as an ethical foundation for the campaign.3 The Charter sought to define medical professionalism for the modern era, and included a social justice principle that featured a commitment to stewardship and prudent management of resources. ABIMF appealed to specialty societies through this concept of physicians’ professional responsibility to their patients and the communities they served to lead in identifying overused tests and procedures. Thus, the Charter was an antidote to dual agency and gave physicians the ethical basis for having such conversations. We sought to appeal to physicians’ intrinsic motivation, relying on physicians’ own motivation to do the right thing and avoiding the “dual agency” problem.
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-Richard J. Baron, MDa,b, Daniel B. Wolfson, MHSAb
This article originally appeared in the May 2019 issue of The American Journal of Medicine.
