The questions Farzad Mostashari, MD, ScM, former head of the Office of National Coordinator for Health IT, and I addressed during this hour-long session centered around the issue of:

What motivates physicians to do great work and how important are financial incentives?

There have been lots of studies and some systematic reviews of the effectiveness of pay-for-performance (P4P) programs. Most of the studies have shown P4P to have mixed results (see below) – sometimes it works to improve quality and reduce costs, and other times, it doesn’t. Success seems to be largely dependent upon:

• The size of the financial incentives;
• The number and quality of indicators; and
• Whether the incentives are given to individual practitioners or to the larger organization.

Systematic reviews published recently include:

• “Effects of pay-for-performance in health care: a systematic review of systematic reviews” – Health Policy (2013)
  • Findings suggest P4P can potentially be (cost) effective, but the evidence is not convincing; many studies failed to find an effect and there are still few studies that convincingly disentangled P4P effect from effect of other improvement initiatives.
• “Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework – a systematic review” – Annals of Family Medicine (2012)
  • Quality of care for incentivized conditions during first year improved at a faster rate than pre-intervention trend and subsequently returned to prior rates of improvement.
• “Does performance-based remuneration for individual health care practitioners affect patient care? A systematic review” – Annals of Internal Medicine (2012)
  • The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain.

When incentives are awarded to the larger organization, they are fairly invisible to the individual physician. These types of incentives can help motivate organizations to put new systems in place, but not always. And the studies show they, too, often have unwanted spillover effects, like teaching-to-the-test, so they don’t necessarily help address ways to motivate physicians to do great work.

P4P is based on a failed fee-for-service system that creates perverse incentives and is like putting a broccoli on a Big Mac.  Per Don Berwick in his article, “The Toxicity of Pay for Performance,” contingency payments are harmful to organizations and individuals.

The alternative is to rely on intrinsic motivation and an individual’s professional values.  But this method fails to meet the “quick fix” requirement policymakers seem to want so they can efficiently recognize, reward and further motivate desired behaviors. A reliance on such intrinsic motivators makes accountability challenging as well. How would you know an individual physician is meeting the desired standards of care and how could you reward him or her?

With policymakers looking to dig their teeth into tangible and measurable methods to motivate physicians and my belief that physicians are more driven by an internal, personal impetus, I propose the following:

1. Compare physicians to their peers on their success in achieving the triple aim and require transparency to their peers and patients on these measures.
2. Set targets and standards that physicians regard as worthy.
3. Recognize exemplars to their peers and the public for providing the best care and making innovations and improvements in care delivery.
4. Create competitions/challenges regarding innovations/improvements and recognize the “winners” in non-financial ways.
5. Hold physicians accountable to achieve standards for performance.
6. For physicians not meeting certain standards of care, provide them with coaching (e.g., through quality improvement organizations) and closer oversight of their performance (e.g., require pre-authorization).

There is no doubt any professional in any field is motivated by financial security but as Daniel Pink articulated in his book, Drive, to get great work out of professionals, we need to appeal to their innate sense of professionalism: their need for mastery, purpose and autonomy. For physicians, this means appealing to their sense of why they entered medicine – to help and to heal with compassion and continuous mastery of skills and knowledge in their chosen field. This is the best way to motivate physicians to do great work.

Based on a technique advanced by the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, during the Forum we conducted a competition that aimed to produce creative ideas around improvements for EHRs and/or measurement. For a conference that could have focused on technical solutions, most of the products attendees came up with were very patient-centered and focused on  better documenting patient information, while also making it  more accessible to both the physician and patient.

The winning idea, the “Global Patient Positioning System – GPPS,” attempted to remedy the multiple screens and clicks clinicians currently have to go through to formulate a complete, holistic view of the patient and their health. As group member Todd Staub, MD, from ProHealth Physicians, stated:

What if we could devise an opening screen that gave a whole-person view of that individual at a glance? How could we capture in a simple way their health status, gaps in care, their goals and values; how that person wanted to be understood and where they were on the journey through life?

The GPPS was envisioned similar to a  GPS system that would guide patients and clinicians on a pathway to wellness. A dynamic circle would appear as the first page of the EHR, which would then be divided into segments. Each segment represented an aspect of total wellness—lifestyle, health habits, family and community support, chronic illness, gaps in care, psychological wellness and economic situation—and would be colored green, yellow or red to illustrate positive or negative values for this aspect of the patient’s health. In the middle of the circle would be a segment labeled “My Goals and Values” and include a photo of the patient, family and even pets.

The GPPS wheel would have two views – a clinician’s view and a patient’s view:

• The patient portal would be authored by the patient, who would ensure the information accurately reflected their own priorities and give them access to decision support and education.
• The clinician’s view would feature evidence-based support. Planned interventions might trigger alerts if they ran counter to the patient’s values and goals.

The excitement and enthusiasm in the room while the competition was taking place was palpable. Not only was I struck by the creativity of the attendees but it also made me realize that the folks in the room were all intrinsically motivated; their reward wasn’t financial, but rather the satisfaction that comes from doing the best job they can.

GPPS is a product that may be coming your way in the future – wouldn’t that make care better and be a wonderful outcome of the Forum?

The topic of this year’s meeting centered around the role of technology in medicine and obviously touched a nerve. There isn’t a physician among us whose work hasn’t been affected by the proliferation of health IT. It was therefore fitting that, as we discussed various strategies for implementing IT into practices and larger organizations, we also talked about how physicians are suffering high levels of burn-out and strategized ways to bring back joy in practice. While at present, IT and joy in practice seem diametrically opposed (as the pressure clinicians are suffering from is, in part, a result of the increased demands of technology), it is important to realize how one can facilitate the other if the IT system is properly designed and implemented.

One of the most repeated themes of the Forum, heard from patients at the meeting and echoed by the physicians present, was the need for current EHRs to capture the patient voice. As one speaker said, we need to shift away from asking a patient “what’s wrong” to “what matters.” These are the data we should be collecting in EHRs because they not only enable physicians to provide high-quality patient care, they allow them to achieve their core purpose—meeting the needs of their patient—which in turn instills a sense of pride and purpose in their work, sentiments not always felt by today’s physicians who are suffering under the burden of IT data requirements.

In addition, attendees were quick to mention that the lack of proper IT training for physicians was contributing to the difficulty of use. We are not using the electronic tools to do what they are good at doing. We are simply using them as a means to an end. Further illustrating this point, doctors are being trained by compliance officers on how to use the technology. This kind of training facilitates payment, sure, but these kinds of IT processes don’t solve clinical issues; they don’t care for the patient.

We were also reminded that design matters… and design never ends. It is an iterative process and one that physicians should be involved in from the beginning. There is no doubt that the poor usability of today’s tools is adding to the frustration clinicians feel as they are faced with mounds of data entry at the end of a busy day. These days, physicians spend almost half of their time in front of a computer terminal rather than caring for patients. It’s no wonder they feel disconnected from the core principles of the profession and cut off from the real rewards that come from meeting patients’ needs.

We were reminded, however, that docs love data. If IT can capture and measure the kinds of data we can consume, analyze and use to provide better and more personal care, it’s a win-win for physicians and patients alike. The potential for health IT is as exciting as it is unknown, and I think everyone who attended the Forum agreed that it’s not a question of forgoing IT altogether, but rather tailoring and refining it to achieve what we would consider true “meaningful use”:  that is, a use that serves our patients and allows us to better meet their needs.

Attendees will hear that system changes, such as the implementation of electronic medical records (EMRs), safety protocols or newly developed measures can sometimes be counterproductive as they can create more work for the health care team and do not always add value for the patient. We will examine problems with EMRs, the administrative burden that is now falling on clinicians and their rate of burnout that can lead to mistakes and less-engaged patients.

The attendees will also learn about innovations currently underway that are addressing some of these problems, including:

• the redesign of ambulatory care;
• information exchange via computer;
• successful EMR implementation;
• systems that permit patients to access their health information;
• the development of better performance measures; and
• the role of leadership and listening to emerging conversations.

Will these innovations, successful on a small scale, spread across the country? Are these changes enough to improve patient care and make healers less prone to burnout?

I believe when clinicians and patients on the frontlines are involved in these conversations together, we will find solutions to the problems we now face.

In a 2012 JAMA “Piece of My Mind” essay, “The Cost of Technology,” author Elizabeth Toll, MD, writes elegantly about physician and patient engagement: “Physicians and patients must speak loudly and clearly, with a unified voice, to address the dehumanizing trends in our profession and insist that the move toward technological reform not leave us with a nation devoid of physician healers.”

In their book, The Doctor Crisis, Jack Cochran, MD, and Charles Kenney call on physicians to lead this charge as healer, leader and partner. They state, “…we need many more physicians who are willing and able to lead from where they stand. A growing cohort of physicians committed to leadership at many levels is critical for the transformation needed in health care.”

This year’s Forum, for me, is not just about technology and transformation. It’s also about two interwoven elements:

• Rebooting the system—starting to reexamine how technology is employed and how its associated regulations create value for patients and add to the well-being of physicians.
• Clinician leadership in partnership with others in taking an active role to fix the clinical environment and reboot it for service and satisfaction.

There is mounting frustration with EMRs and measurement. Might this conference be used as a fresh new look at how to solve these challenges? Certainly, the right people are in the room for this conversation to occur.

Choosing Wisely recommendations from the American College of Cardiology (ACC), the American Society of Echocardiography (ASE) and the American Society of Nuclear Cardiology (ASNC) all recommend against echocardiograms (ECHO) or electrocardiograms (ECG or EKG) for asymptomatic patients:

• ACC: Don’t perform ECHO as routine follow-up of mild, asymptomatic native value disease in adult patients with no change in signs and symptoms.
• ASE: Avoid using stress ECHOs on patients who meet “low risk” scoring criteria for coronary disease.
• ASNC: Don’t perform cardiac imaging for patients who are at low risk.

I urged the physician who e-mailed me to write to the academic medical center that was using the HealthFair’s mobile screening services, which he did. I promised I would further explore the issue. Upon investigation, I found that the consumer rights advocacy group, Public Citizen, already had HealthFair on its radar.

On June 19, Public Citizen released a statement urging hospitals to sever their ties with HealthFair Health Screening. The title of its statement pretty much says it all:

HealthFair’s Cardiovascular Screening Packages Are Unethical, Mislead Consumers, Do More Harm Than Good: Public Citizen Calls on 20 Hospitals and Other Medical Institutions in Eight States to Sever Relationships With Company Over Unnecessary Screening Programs.

Dr. Michael Carome, director of Public Citizen’s Health Research Group, said in Public Citizen’s statement, “It is exploitative to promote and provide medically non-beneficial testing through use of misleading and fear-mongering advertisements in order to generate medically unnecessary but profitable referrals to the institutions partnered with HealthFair… This screening also violates many ethical principles, such as the duty to promote good and act in the best interest of the patient and health of society, the duty to do no harm to patients and the duty to protect and foster a patient’s free, uncoerced choices.”

HealthFair responded to the criticism: “HealthFair stands by our program to educate the consumer, pre-select those that are candidates by screening, and provide them with the choice to obtain testing.”

I am glad to see that Choosing Wisely has increased the sensitivity around issues of value and overtreatment in the screening arena. The campaign has emboldened others to not only recognize these issues but also take action.

Who knew that Mary Poppins’ advice could apply to reducing waste in health care? Apparently, the Society of Hospital Medicine (SHM) and the Minnesota Medical Association (MMA) did. To get their members fired up about implementing Choosing Wisely, both organizations are inviting their members to engage in a little friendly competition.

SHM will award eight prizes totaling $20,000 to the winners of their Choosing Wisely Case Study Competition. The competition provides an opportunity for hospitalists to share projects that have facilitated the successful implementation of one or more recommendations from SHM’s Choosing Wisely list. Submissions will be evaluated on:

• Demonstrated  improvement in appropriate utilization
• Demonstrated ability to succeed in sustaining efforts
• Innovation in achieving improvement
• Reduction in wasteful spending
• Institutional commitment to achieving improvement (i.e., demonstrated institutional support/buy-in)

The competition formally launched on June 30, 2014 and ends September 9, 2014. Projects must have begun after January 1, 2013 and the first author of the competition write-up must be an SHM member in good standing. One hospital/individual may submit multiple projects in multiple submissions. If you have any questions, please contact Jenna Goldstein at jgoldstein@hospitalmedicine.org.

MMA’s video competition aims to increase physician awareness of the Choosing Wisely campaign. The competition is a result of a suggestion by one of the residents on the organization’s steering committee and asks MMA members to create a short video (five minutes or less) about Choosing Wisely and upload it to YouTube. The steering committee will select the top two videos; winning videos will receive a share of a $400 prize and be played at MMA’s annual meeting in September. A “People’s Choice Award” will also be named; top videos will be shared with the public to enable friends, family, co-workers and interested Minnesotans to pick their favorite.

Submissions will be accepted through September 2014. To find out more, visit: http://www.mnmed.org/Advocacy/Choosing-Wisely/Choosing-Wisely-Video-Contest

Your institution has ceded to me the last 15 minutes of your medical school instruction – how should I use it? One more time through the complement cascade? Or, as Dr. Seldin might have it, a final discussion of salt wasting in chronic renal disease, or, perhaps, the causes of metabolic acidosis? My guess is that you would sleep through that (as I slept through so many medical school lectures), but the good news is that many of those things are going to change–dramatically–over the course of your careers. Change in medicine is a constant, sort of. Many things DO change, but some core things don’t. Let’s spend some time reflecting on that. Hippocrates didn’t write about essential thrombocytosis, Benjamin Rush, an 18^th century Philadelphia physician and signer of the Declaration of Independence, never made a diagnosis of osteoporosis and William Osler did not review hyperparathyroidism in his Principles and Practice of Medicine. Now, none of these men were considered ignorant or uneducated during their medical lives; to the contrary, all were thought to be excellent physicians in their day. But you can’t make a diagnosis of thrombocytosis if you don’t have a way to count platelets, you can’t diagnose osteoporosis without DEXA scanning and you can’t make a diagnosis of hyperparathyroidism if you don’t have access to sophisticated clinical chemistry laboratories. At any given time, we do what we can do with the theories, knowledge, technology, payment and culture that we have available at that time.

T. S. Kuhn, a famous historian of science, is the guy who coined the term “paradigm shift”. He observed that scientists tell their history as a linear saga of continuous improvement: in our conventional “textbook” history, we just get smarter and smarter and better and better. But Kuhn realized that we have real “discontinuities”, “inflections”, where the very way we think about science changes. He calls those “scientific revolutions”—paradigm shifts—and says they happen when science is failing to solve problems society believes are “important”. Well, I think it is pretty clear we are failing to solve a lot of the problems society deems important, and I think we are in the middle of a pretty big paradigm shift right now.

What are the “important problems we are failing to solve?” Care is too expensive; it is of inconsistent and unreliable quality; and the experience of patients in the health care system is not wonderful. This has been summed up in the “Triple Aim”, which is at the heart of our national health care strategy: increase quality, improve patient experience and decrease total cost of care. No problem, right? We ALL know how to do that, right? Or maybe we don’t. More about that in a minute.

But medicine has actually had a LOT of “scientific revolutions” with big changes in what we do and what we believe “works”: Rush was a big fan of bleeding and purging, and Osler treated typhoid fever with cold baths. So what DOESN’T change in medicine? What can you all hang on to over the course of your own changing medical lives?

In their book, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma define medicine as “a meeting of at least two personal intentions, one seeking help and the other offering it.” Over the course of my own career in practice and in policy, I have never found a better definition of what I was trying to do, a better way to frame and understand the myriad micro- and macro- choices facing me and my colleagues. My patients were the ones seeking help; I was the guy offering it. Sometimes, I got it right; lots of times, I got it wrong. I would be trying to use what I knew in the service of my patients.

A year ago at this time, I had the incredible good fortune to be standing at the Hippocratic Studio on the beautiful Greek island of Kos: big, grand ruined buildings. Maybe what UT Southwestern buildings will look like in two or three thousand years?  We don’t know much about the specifics of the patient experience there, or the techniques the doctors used. And I suspect the intricate theories under which you are developing the latest biologicals to treat lupus will be obscure to those tourists clambering over the ruins of your labs and trying to figure out what went on here. But I am certain that however they did what they did at the Hippocratic Studio at Kos, the people who came shared the predicament of our patients today, and the workers in the Hippocratic Studio shared that same durable intention: to help. So with all the things that will change over the course of your careers, perhaps you can hang on to that.

I was lucky enough to practice medicine for almost 30 years in the community in which I lived in Philadelphia. A century before I did, so did Dr. Owen Wister. In 1857, Dr. Wister wrote to his wife:

I was almost afraid that I might not be able to write today, for last night I came home early, with the intention of going to bed by 12 o’clock but at that hour was called out, returned at 2, was again called out at 2:30 and finally appeared at 6, in time to get a bath, eat breakfast and go out for the morning at 8. (This was, of course, before ACGME put in Duty Hour restrictions!)

In 1858, while his wife was vacationing in the hot springs at Saratoga, he wrote to her explaining why he could not join her:

At this moment I have in my care some people severely and dangerously ill, and so affected that I could not ask them to see anyone else, not that anyone else would be less suitable, but I am their physician- they have confided to me what must have cost them no trifling sacrifice of feeling, and can I ask them to uproot this in order that I may yield to a temptation [to travel]?

As I did and many of you will, he often took care of friends and their families. When his friend’s son became ill, he sent for Wister. This is from his friend’s 1858 diary entry: He [Wister] came at 5 yesterday.  [Little] Sidney no better but no worse. He ordered Dover’s powders.  Came again at 10 last night. He then told me that it was membranous croup, but that the child was better & he thought he could check the disease.  . . .  He came again this morning, and the baby was better . . . there was no longer cause for anxiety.  What a great thing is science. But for this, our baby would in all probability have died, as many thousands die for want of skillful treatment.

“Dover’s powders”? Science “a great thing”? Guess we’ve had some scientific revolutions since then.

With Wister’s romantic image firmly in mind, let’s get back to that “changes” thing. There ARE going to be huge changes, because we need to figure out how to achieve that Triple Aim. I want to reflect on three broad transformational forces affecting all of you that will be bringing us closer to Triple Aim outcomes. I believe you can make sense of them using your intention to help as your compass. The three areas: information technology; payment systems; and the organization of physician practice and health care delivery.

I know it’s a cliché to talk about how computers are changing everything, and not just in health care. As I noted earlier, there is a constant iterative dialog between how we do medicine and the technology we have to do it with. In general, people use technology to solve a problem. Computers found an early use in medicine built into the machines that gave us advanced imaging, and computers also found a path into health care, as they had in so many businesses, to handle financial transactions: billing, coding, claims processing. These were both “familiar” uses of computers: solve a business and financial problem and understand pathological and healthy anatomy. But the “revolutionary” use of computers in health care will come from the continuous availability of “numerator-denominator” data about our performance as a core feature of medical practice.

We used to hold ourselves accountable for “knowing what to do” – who should and who should not have a mammogram? Now we are holding ourselves accountable for knowing the answer to the question, “Of all the women I saw last year who SHOULD have had a mammogram, what percentage of them actually DID?” It used to be we doctors only had data like this was when we did studies: we paid chart abstractors to audit charts and count things, but only for research. I believe this continuous understanding of your performance will be as much a part of your practice as using a stethoscope was for Dr. Seldin.

Many have said that computers are a barrier to patient centered care; I simply don’t believe that.  All technology CAN be used as a barrier—which of us hasn’t plugged into the safe silence of our stethoscopes while “listening” to our patients?—but it can also be a tool used to help us achieve very patient-centered goals. A colleague tells the story of a 70-year-old engineer who, at his first visit, thrust out his hand and said, “My name’s Chuck Schiedle, rhymes with Needle.” Now Schiedle had an odd spelling, S-C-H-I-E-D-L-E, which folks would reliably and predictably mispronounce. My colleague “tricked” his EHR to show, to whomever opened the chart, right under the name, the phrase “Schiedle, rhymes with needle”. He figured out a way to use his EHR to achieve a very patient-centered goal: “everyone in my office will get your name right.” You will not learn that use of information technology from the many compliance officers you will meet who will explain the requirements of Meaningful Use, but it is clear that this use of an EHR was pretty “meaningful”!

In my own practice, we referred many patients for screening colonoscopy, a clearly valuable clinical preventive service. Our standard approach, using our EHR, was to advise the patient to do it, print a letter they could take to the GI office, and encourage them to schedule the appointment. I know you will all be shocked to learn that many patients simply didn’t follow through! So we tried another approach: we asked patients if it would be OK for us to share their contact information by e-mail with the GI group we usually used, and we worked with the GI group to agree that, upon receiving this information, they would call and offer appointments. Guess what happened: the rate of completed colonoscopy using the “paper referral” method was 29%, but it was 42.9% for patients with e-referral. That is a 47.9% relative improvement in the rate at which colonoscopy was actually completed on those patients!

You will have many opportunities of your own to figure out how to use information technology to meet the needs of your patients. Don’t let the Meaningful Use police circumscribe all your creative uses of technology!

Payment systems in health care are also going to change pretty dramatically during your career, but before you despair and get influenced by colleagues who tell you how terrible all these changes are, keep a few things in mind. Payment and systems to administer it will always be challenging for doctors, and they will always be imperfect. Physicians used to be a lot more economically marginal in the U.S. than we are today. Consider this advice, offered by Benjamin Rush in an 1805 book written for medical students and young doctors:

“The resources of a farm will prevent your cherishing, even for a moment, an impious wish for the prevalence of sickness in your neighborhood.”

And a century later, in New York City, it was not much better. In 1895, John Sedgwick Billings, a Hopkins-trained socially connected doctor, tried to set up a private practice and wrote to his wife:

“If my patients would only pay up!  But that is the hopeless despairing cry of every D–n Fool of a young doctor in New York- or elsewhere.” 

We’ve come a long way from there, of course, with insurance companies and governments mediating payment arrangements for patients and enabling a much more capital-intensive health care system with many more machines and laboratories and pharmaceuticals than we ever could have gotten without them, and WAY higher incomes than any 19^th century physician dreamed of. But I think it is fair to say that one of our major problems in health care could best be described as “defective procurement”. Payers, committing to pay for health care services on behalf of patients, precisely specify what they are buying, so we have a clear definition of a right knee MRI. Having created a world in which payment for those services is available, we sure get a lot of them. The problem is, nobody WANTS a right knee MRI! They want to play tennis, or crawl around with their grandchildren, and we haven’t figured out how to buy THAT.

Well, I think the best way to understand payment change is as a continuing effort to buy what patients really need, and to encourage all of us to organize institutionally to deliver that. When an elderly lady falls and breaks her hip, if all goes wonderfully well, she will be treated in an ER, go to an OR, have a successful operation and go home. And then she will get separate bills from an ER group, a hospital, a radiologist, an anesthesiologist, an orthopedist, and maybe a physiatrist or physical therapist. All of those services were completely predictable from the moment she fell and broke her hip, but we pay for them one at a time. You wouldn’t buy a watch or a car that way, would you? You know it would cost more and be harder to assemble, right? Well, we aren’t going to keep buying health care that way either.

As you see and experience these dramatic payment changes, realize they are not about you! There is nothing “natural” or “automatic” about the payment system we have, which has many perverse consequences. Your future leadership as physicians will be desperately needed in making it work better for the patients all of us serve. And, of course, changes in payment are going to drive changes in the way care is organized.

Unlike Dr. Wister, we are not solo actors working in farm houses at 3 AM. The image still inspires us, as well it should: somebody has a need, somebody is offering to help. Today, we can do more for our patients than Dr. Wister could EVER do in those farm houses. But we do it the way advanced societies achieve amazing things, like building the new hospital I toured earlier today with Dr. John Warner, an interventional cardiologist turned construction supervisor and hospital CEO: we do it in complex teams of highly differentiated function.

As physicians, you will have a critical role on those teams: sometimes as a leader, sometimes as a follower. Those teams need to focus on putting together the things patients actually want and need from health care. You may be the orthopedic surgeon who does the amazing knee operation, but you need an OR staff to support you, a billing group to pay you, multiple other health professionals to get her moving and playing with her grandchildren, and an IT team to assure that everyone touching her has the critical information they need to provide safe, informed care. NO ONE has a privileged role in this besides the woman with the broken hip. EVERYONE else is working together to meet her need, reliably, efficiently and well. Always remember that our patients are not “guests in our hospital”; we are “guests in their lives.”

But back to Dr. Wister. I have some bad news about him: he crashed and burned doing practice at the pace I have described. You, too, are going to face many pressures to lose your idealism and become cynical. You are going to encounter colleagues who tell you “you need to understand how the world REALLY works,” who invite you to substitute their despair and frustration for what you aspire to and think is possible, and you will need some survival skills to help you. So, in conclusion, I’ll offer a few:

• Stay curious and seek understanding. When you see something REALLY dumb (you’ll see a LOT of that), work hard to imagine why somebody thought that was a good idea, how that could be understood as trying to solve a different problem than the one occupying you at the moment you encounter it. And try to find a better way to solve BOTH problems, yours and the other person’s.
• Seek value congruence in all the institutional affiliations you make – the deeper, the better. Don’t go anywhere for the money or the prestige.  You’ll regret it.
• Stay focused on your patients: it’s not about you.  YOU are about THEM!
• Perhaps most important: DO take that vacation with your spouse that Wister didn’t take, and DO take the day off to see your kid in the school play. You will be a better doctor because you did!
• And don’t ever forget all those people who got you here. Celebrate with them your wonderful beginning as a doctor, and let them remind you who you are and why you do what you do every day.

Thanks for giving me the chance to share your magnificent day!

Overtreatment has been on the minds of journalists, politicians, patients and physicians in this country over the past few years. The Choosing Wisely campaign was launched amid the passing of the Affordable Care Act and nascent conversations around health care costs and stewardship. I’d like to think that Choosing Wisely has had an impact on those conversations.

In thinking about Choosing Wisely’s future, I was reminded of my past. Twelve years ago, when I began working for the ABIM Foundation, I read the Physician Charter and was immediately attracted to its fundamental principle of social justice. There are many definitions of social justice in health care but the dozen writers from ACP Foundation, European Foundation of Internal Medicine and ABIM Foundation were quite explicit about what it meant in relation to the health care community:

The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or any other social category.

There is a connection between this principle of social justice and the fundamental tenets behind Choosing Wisely. For example:

• The campaign could be seen as a means to level the playing field for all patients in that it broadens access to needed care by identifying what tests and procedures are not necessary and by eliminating waste.
• Providing wasteful health care services makes it more difficult to access care that is actually needed. If a clinical office has the capacity to deliver 50 x-rays in a day and 25 are not necessary, patients that need the test are forced to wait. Usually, those who have most difficulties getting access to care are disadvantaged populations.
• In order to preserve the sustainability of our system, health care resources need to be distributed to patients that need care. They should not be wasted on care that has no benefit and could be potentially harmful. Wasteful services adversely affect the focus on improving the health of the population. The resources used up by wasteful health care expenses could be better spent on improving education and infrastructure. Rosemary Gibson, author of Medical Meltdown, reports that roads and infrastructure go unattended in China, Maine, because of the high costs of care partially due to unnecessary care.

If we are to have a high-quality and affordable health care system, the just distribution of services needs to be a basic tenet of the medical profession and society. Through Choosing Wisely, the profession can examine the consequences of waste on larger societal issues and hopefully change things for the better.

There are many ways medical professionalism has been “taught” to medical students, residents and practicing physicians throughout their continuous professional development¹. For example:

• Theory and cognitive base are taught in the classroom, focusing on traits or characteristics
• Discussions around professionalism issues result from experiential learning
• Role models influence the informal and hidden curriculum around professionalism
• Professionalism of students/residents is assessed by faculty

While the above are all good tactics, I have always felt that something has been missing to cultivate a sense of professionalism among physicians that becomes ingrained in everything they do. Understanding Professionalism attempts to bridge this gap through:

1. A focus on the behaviors of professionalism rather than intractable characteristics of the learner.
2. Presenting professionalism in service as meeting the needs of the patient, to be used as a force for continuous improvement of health care rather an end unto itself.
3. Exploring how organizations’ behaviors and policies (i.e., payment systems) influence professional behaviors.
4. Assisting clinicians through conflicts that are present on a daily basis rather than focusing on potential punitive actions that result from unprofessional behavior.
5. Focusing on acting as a professional as part of a clinical team rather than an isolated sole practitioner.
6. Emphasizing the positive aspects of being a professional though an individual’s sense of pride in being a healer and physician.

This book presents an active learning of professionalism through clinically realistic vignettes, learning exercises and challenge cases (similar to but somewhat different than a case study). Professionalism comes alive in this book; it becomes practical and relevant. This book is a must-read for all if we are to see professionalism grow and continue to be a strong force in improving the quality of care for patients and improving the lives of their healers.

¹ Teaching professionalism: general principles Med Teach In Medical Teacher, Vol. 28, No. 3. (1 January 2006), pp. 205-208, doi:10.1080/01421590600643653 by Richard L. Cruess, Sylvia R. Cruess

A couple of weeks ago, I presented and participated in a two-day conference sponsored by the Commonwealth Fund and led by Choosing Wisely Canada champion, Wendy Levinson, MD. (Dr. Levinson is also a Trustee of the ABIM Foundation and former chair of ABIM.)  Conference attendees hailed from Australia, Canada, the Netherlands, Italy, Japan, the United Kingdom (including a representative from Wales), Germany, New Zealand, Switzerland and the United States.

Fittingly, the event took place at The Waag in Amsterdam–a 15^th century building and former home of the college of surgeons. The venue boasted a large theater which housed the famous Rembrandt painting, “The Anatomy Lesson of Dr. Nicolaes Tulp” (1632). The painting did not go unnoticed by attendees and seemed to inspire our discussion.

• Tai Huynh, MD, campaign manager from Choosing Wisely Canada, tweeted on the conference: “Patients should have a voice in #Choosingwisely and not to be (sic) a dead corpse.”
• Terence Stephenson, MD, from the UK referenced the painting when speaking about the contents of the recommendations, particularly in reference to “getting them right”—unlike the painting which, as he pointed out, is not physiologically accurate.

One of the discussions centered around the essential  principles of a Choosing Wisely campaign. These included:

• Fostering patient-physician conversations and relationships, including shared decision-making;
• A physician-led, physician-owned campaign;
• Evidence-based recommendations;
• A multi-professional team approach to the recommendations; and,
• Transparency of the process used to develop recommendations.

One of the biggest differences between how we have discussed Choosing Wisely in the U.S. and how our international counterparts are talking about it centered around the issue of cost. Costs featured more prominently in my colleagues’ thinking, while professionalism took more of a back burner. For example, cost is explicitly mentioned in Netherland’s campaign brochure:

The goal is for care professionals and patients to work together to realize quality improvements in care, while keeping costs under control. The campaign is meant to answer the question of how we can spend the ‘care euro’ as efficiently and practically as possible, especially as the cost of care continues to rise.

As each country faces pressure to show the results of the campaign, cost is a measurable part of that evaluation and is expected by payers and their respective governments. I am very interested in seeing how putting cost upfront rather than emphasizing professional values will affect public and physician engagement throughout the world, particularly in light of each country’s different medical system. Perhaps there is a collective understanding among the public in these countries around the implications  the high cost of health care has on all aspects of society (i.e., less money for education and infrastructure, and higher taxes).

I wonder which of the principles above will make the campaign work in each country… and why. I look forward to the results.

Rembrandt – The Anatomy Lesson of Dr. Nicolaes Tulp (1632)