Choosing Wisely

A few years ago, the American Board of Internal Medicine launched the Choosing Wisely campaign to help physicians and patients choose care that would, over time, combat the rising healthcare costs in the US.  The initiative’s primary strategy is to provide evidence-based recommendations on when medical tests are appropriate, especially for those tests that are deemed to be overused.

Having trained at a place where resource stewardship was required, it became second nature to use these lists for clinical decision making when practicing medicine in the US.

Today, “choosing wisely” has a whole new meaning.  Before, I was selecting from a seamlessly never-ending menu of investigations and therapeutic modalities; hence the need for initiatives like Choosing Wisely.  Now, those lists of options are very limited and at times, non-existent.  Thus, “choosing wisely” here manifests like…

  • We are out of a commonly used intra-venous antibiotic.  Do I choose to have the family go try to buy it at a local pharmacy, or do I use a less desirable drug?
  • We only have one dialysis catheter left, and two patients desperately need dialysis to get them through their acute illness.  Do I choose the patient with the best prognosis, the youngest patient or the one admitted first?
  • Our hospital is completely out of oxygen.  Do I choose to use the torpedo-sized tanks procured from two other hospitals on the medical ward where the average age and oxygen saturation is in the mid-70s, or in our NICU (newborn unit) for CPAP?
  • Our blood bank is as anemic as the patients.  So, who do I choose to transfuse with those precious units of blood?

At my own doorstep, choosing wisely takes shape in other ways.  For a while, I was the only expat medical physician here so the choice of whether I could turn off my phone was made for me.  I was called.  I went.  Now, there are several more expat medical physicians here to work and serve, but many of them are still learning the ropes and need support.  Thus, turning my phone off is still hard to do.  However, I know that answering that call may result in another missed Saturday morning of pancakes or another much needed conversation ending prematurely.  That said, choosing to answer or to go in when I’m not the physician on call seems like a necessary discomfort for my family and me, in the hope that others will grow in knowledge, confidence and capability.  

Every day we all are faced with choices.  Each time I leave for work, I remind Sylis to “make good choices” with the hope he will be thoughtful about his decisions and their impact, not only for himself, but for those who are likewise affected.   He will soon figure out, as I have depicted above, that choosing wisely does not always fit into the binary construct of good and bad.  Sometimes we are left with choosing between bad and worse. 

The adverb wisely implies experience, knowledge and good judgement.  Reflecting on the required decisions above and others unmentioned, I am certain I have chosen poorly more often than wisely.  Therefore, I ask that you keep us in your thoughts and prayers as we consider what “choosing wisely” looks like in the hospital, our community and our home.