American Board Of Internal Medicine Foundation Research Articles

Choosing Wisely in oncology in Latin America: what SLACOM does not recommend in the care of cancer patients in Latin America: Ten essential recommendations to avoid harmful onclogy procedures in Latin America.

Choosing Wisely is an initiative by the American Board of Internal Medicine (ABIM) and ABIM Foundation to deter unnecessary medical treatments and procedures. Faced with the burden of modern technologies and treatments, it is crucial to identify practices lacking value in daily care. The Latin American and Caribbean Society (SLACOM), comprising cancer control experts, deems it vital to tailor this initiative for enhancing cancer care in the region. Through a modified DELPHI methodology involving two rounds of electronic questionnaires and a hybrid meeting to discuss key points of contention, ten essential recommendations were identified and prioritised to avoid harmful oncology procedures in our region. These consensus-based recommendations, contextualised for Latin America, have been compiled and shared to benefit patients. The Scientific Committee, consisting of prominent oncologists and health experts, collaborates remotely to drive this project forward.

Exemplars Illustrating De-implementation of Tradition-Based Practices.

Clinical practice must be based on evidence. When evidence suggests that a certain practice may be ineffective or even harmful, that practice should be discontinued. The Choosing Wisely campaign, an initiative of the ABIM (American Board of Internal Medicine) Foundation, is intended to bring attention to tradition-based practices, or "sacred cows," which lack evidence to support their ongoing use. The complex process of discontinuing or reducing the use of tradition-based practices is known as "de-implementation." Recognizing the importance of de-implementation is necessary to fully understand evidence-based practice. This article explores the de-implementation process, examining its barriers and facilitators. Three critical care exemplars of tradition-based practices are presented and examined through the lens of de-implementation. Barriers and facilitators related to de-implementing these tradition-based practices are described, with an emphasis on the roles of various stakeholders and the need to overcome cognitive dissonance and psychological bias.

Improving Trust Between Learners and Teachers in Medicine.

Improving Trust Between Learners and Teachers in Medicine.

Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial.

Electronic resources are increasingly used in medical practice. Their use during high-stakes certification examinations has been advocated by many experts, but whether doing so would affect the capacity to differentiate between high and low abilities is unknown. To determine the effect of electronic resources on examination performance characteristics. Randomized controlled trial. Medical certification program. 825 physicians initially certified by the American Board of Internal Medicine (ABIM) who passed the Internal Medicine Certification examination or sat for the Internal Medicine Maintenance of Certification (IM-MOC) examination in 2012 to 2015. Participants were randomly assigned to 1 of 4 conditions: closed book using typical or additional time, or open book (that is, UpToDate [Wolters Kluwer]) using typical or additional time. All participants took the same modified version of the IM-MOC examination. Primary outcomes included item difficulty (how easy or difficult the question was), item discrimination (how well the question differentiated between high and low abilities), and average question response time. Secondary outcomes included examination dimensionality (that is, the number of factors measured) and test-taking strategy. Item response theory was used to calculate question characteristics. Analysis of variance compared differences among conditions. Closed-book conditions took significantly less time than open-book conditions (mean, 79.2 seconds [95% CI, 78.5 to 79.9 seconds] vs. 110.3 seconds [CI, 109.2 to 111.4 seconds] per question). Mean discrimination was statistically significantly higher for open-book conditions (0.34 [CI, 0.32 to 0.35] vs. 0.39 [CI, 0.37 to 0.41] per question). A strong single dimension showed that the examination measured the same factor with or without the resource. Only 1 electronic resource was evaluated. Inclusion of an electronic resource with time constraints did not adversely affect test performance and did not change the specific skill or factor targeted by the examination. Further study on the effect of resource inclusion on other examinations is warranted. ABIM Foundation.

Choosing Wisely Champions Spark Innovation in Health Care

![Graphic][1] Unnecessary and wasteful practices in medicine continue to burden an already strained healthcare system. The current healthcare climate, however, provides pathologists and laboratory professionals a remarkable opportunity to lead the way in reducing unnecessary, often harmful testing while improving patient care. In collaboration with the American Board of Internal Medicine (ABIM) Foundation, ASCP would like to recognize several individual clinicians, as well as clinician teams, and their commitment to the ABIM Foundation's Choosing Wisely campaign. Since ASCP joined the Choosing Wisely campaign in 2013, many of its members have worked to advance the campaign's ideals, which intend to reduce waste in health care, in part by encouraging clinicians and patients to question which tests are really necessary, in order to decrease test overuse and improve the nation's healthcare system. “The Choosing Wisely Champions program recognizes clinicians for their contributions to the campaign, inspires clinicians seeking to implement Choosing Wisely in their own practices, and demonstrates how clinicians are driving change in health care,” says Lee H. Hilborne, MD, MPH, DLM(ASCP)CM, FASCP, chair of the ASCP Effective Test Utilization Subcommittee. “Clinicians can learn from one another by highlighting exemplars.” The Choosing Wisely Champions were chosen for advancing Choosing Wisely in their practice, playing a major role in the development of ASCP's recommendations, educating ASCP members about Choosing Wisely , conducting measurement of recommendations, validating research on the importance of recommendations, and demonstrating leadership of a local Choosing Wisely effort. Below are the honorees and a synopsis of their achievements. ### Jason Baron, MD; Anand Dighe, MD; John Branda, MD The Division of Laboratory and Molecular Medicine in the Department of Pathology at Massachusetts General Hospital (MGH) hosts a highly active, … [1]: /embed/inline-graphic-1.gif

A commitment to high-value care education from the internal medicine community.

The Alliance for Academic Internal Medicine, American Board of Internal Medicine (ABIM), ABIM Foundation, and American College of Physicians are collaborating to enhance the education of physicians in high-value care (HVC) and make its practice an essential competency in undergraduate and postgraduate education by 2017. This article serves as the organizations' formal commitment to providing a foundation of HVC education on which others may build. The 5 key targets for HVC education are experiential learning and curriculum, environment and culture, clinical support, regulatory requirements, and sustainability. The goal is to train future health care professionals for whom HVC is part of normal practice, thus providing patients with improved clinical outcomes at a lower cost.

Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)

In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.

Communicating information about “what not to do” to consumers

BackgroundAmericans devote more resources to health care than any other developed country, and yet they have worse health outcomes and less access. This creates a perfect set of opportunities for Consumer Reports, a nonprofit consumer advocacy and multimedia organization known for its focus on individual consumers in markets where significant amounts of misinformation is in play. Consumer Reports uses comparisons/ratings based on the best available data to “level” the market playing field. While our early efforts to inform consumers of overuse and underuse in health care were successful, we sensed there were opportunities to have greater impact. Over a 5-year period, with the help of many partners, Consumer Reports learned more about how to communicate “what not to do” to consumers, ultimately enhancing the effectiveness of this difficult message.AnalysisConsumer Reports began an in-depth examination of the overuse of health services in 2010 with an exploratory review of the cognitive psychology literature. Lessons learned from this review were used in the presentation of subsequent ratings of heart disease and cancer screening tests. Surveys showed surprising gaps in the prevention/screening knowledge of healthy, low-risk Consumer Reports subscribers aged 40 to 60 years. Of these subscribers, 44% reported engaging in heart screening tests that received the lowest ratings from the U.S. Preventive Services Task Force and from Consumer Reports. At the same time professional societies and the ABIM (American Board of Internal Medicine) Foundation created Choosing Wisely®, a campaign focused on identifying lists of health tests and treatments not to do. Consumer Reports joined the Choosing Wisely campaign as the consumer “translator” and organizer of a network of consumer organizations with access to tens of millions of consumers. Over the past year, Consumer Reports has conducted multiple qualitative evaluations of content related to overuse of health services. Ratings of cancer screening tests were released in 2013 in an article readers reported as one of the most heavily read articles in the magazine’s recent history.ConclusionsTelling consumers that more is not better is not a popular or easy message to deliver. The message is most likely to be “sticky” but is best received if it comes from trusted sources (e.g., physicians), focuses on safety when justified, is communicated in plain language, and uses both mass media and individual consumer approaches. Changing the culture of health care in an era of health reform is an essential part of the transformation needed if we are to allocate finite resources fairly in hopefully fair markets while assuring that better quality products and services at lower prices dominate.

APA Joins Campaign Urging Doctors, Patients to Choose ‘Wisely’

Back to table of contents Previous article Next article Community NewsFull AccessAPA Joins Campaign Urging Doctors, Patients to Choose ‘Wisely’Vabren WattsVabren WattsSearch for more papers by this authorPublished Online:30 Oct 2013https://doi.org/10.1176/appi.pn.2013.10b31AbstractThe nationwide campaign known as Choosing Wisely, which APA recently joined, is designed to spur conversations about what medical treatments are appropriate and necessary.September marked the inauguration of APA’s public involvement in the Choosing Wisely campaign—an initiative that encourages physicians, patients, and other health care stakeholders to engage in a dialogue concerning potentially unnecessary medical procedures that, in some instances, could result in harm.The initiative, sponsored by the American Board of Internal Medicine (ABIM) Foundation, was launched April 2012 with nine physician specialty societies in an effort to move physicians towards better stewardship of health care resources. APA joined the campaign earlier this year.According to the ABIM Foundation, the current delivery of health care in the United States “contains too much waste”—with consumer organizations reporting as much as 30 percent of delivered care as duplicative or unnecessary in improving patients’ health outcomes. The Choosing Wisely program requires participating organizations to identify specific tests or procedures that are commonly used but not always essential in their respective fields—APA chose to address the prescription practices of antipsychotic medication.“Antipsychotic medications have tremendous benefits and improve the quality of life for many people with serious mental illness; however, they carry risks including potentially harmful side effects. Unnecessary use or overuse of antipsychotics can contribute to chronic health problems, such as metabolic, neuromuscular, or cardiovascular problems, in people with serious mental illness,” said Joel Yager, M.D., chair of the APA Council on Quality Care (COQC).To identify practices that are sometimes deemed as nonessential, a work group of COQC members developed a list of 21 topics that addressed issues from the use of second-generation antipsychotics to routine neuroimaging. More than 100 members from various APA councils—including the Council on Children, Adolescents, and Their Families and the Council on Geriatric Psychiatry—were surveyed to rate topics and ultimately identify the top five items they thought should be addressed. The items were rated on cost, efficacy, and impact on patients’ health.The final list was approved unanimously by the APA Board of Trustees Executive Committee. The process, from initiation to public release, took nine months.“APA has recommended that antipsychotics should not be used routinely and should never be used without considerable thought, good clinical reasoning, and discussion with patients as to why under particular circumstances such a course would be preferable to alternative options,” said Yager.The cautionary principles issued by APA as part of the Choosing Wisely campaign are as follows:Do not prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.Do not routinely prescribe two or more antipsychotic medications concurrently.Do not use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.Do not routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.Do not routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.Since the public release of the principles, APA has issued a clarification stating that antipsychotic medication may also be an appropriate first-line option for children and adolescents who have a diagnosis of bipolar disorder and irritability associated with autism spectrum disorder. “[APA] has shown tremendous leadership by releasing its list of common uses of medication that aren’t always necessary,” stated Richard Baron, M.D., president and CEO of the ABIM Foundation. “The content of this list and all of the others developed through the Choosing Wisely effort are helping physicians and patients across the country engage in conversations about what care they need and what we can do to reduce waste and overuse in our health care system and improve overall health.”The Choosing Wisely campaign points out that its recommendations are provided solely for informational purposes and should not be used to establish insurance coverage decisions or exclusions. ■Read more about Choosing Wisely and APA’s involvement with the campaign at http://www.choosingwisely.org/ and http://www.psychiatry.org/choosingwisely. ISSUES NewArchived

"Choosing Wisely" to Reduce Low-Value Care: A Conceptual and Ethical Analysis

The American Board of Internal Medicine (ABIM) Foundation has recently initiated a campaign called "Choosing Wisely," which is aimed at reducing "low-value" care services. Lists of low-value care services are being developed and the ABIM Foundation is urging the American Medical Association and other organizations to get behind the lists, disseminate them, and implement them. Yet, there are many ethical questions that remain about the development, dissemination, and implementation of these low-value care lists. In this paper I argue for conceptual clarity with respect to the label "low-value care." Thus far it has not been precisely defined, and I argue that there are actually 10 distinct categories of low-value care. I discuss the ethical challenges and considerations associated with each category. I also provide arguments that can be used to justify the reduction of some of these categories of low-value care. These arguments rely on Rawlsian and Hegelian notions of justice, as well as on concepts about the fiduciary obligations of physicians. Finally, I outline the various mechanisms that could be utilized for the reduction of low-value care (i.e., incentives, punishments, nonrational influences such as appeals to social norms, emotions, or ego, and creation of conditions that make avoidance easy such as defaults and reminders). I provide normative guidelines for the use of each.

Weighty talks about wise choices

Weighty talks about wise choices

Choosing Wisely

WHILE THE UNITED STATES GRAPPLES WITH THE challenge of health care costs that contribute to high rates of poor-quality care, burdens to business competitiveness, and looming government deficits, clearly there are areas in which health care spending does not add to the health of individuals and communities. The polarizing political environment makes it difficult to conduct rational public discussions about this issue, but clinicians and consumers can change the nature of this debate to the potential benefit of patients, the medical profession, and the nation. The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm. In fact, some estimates suggest that as much as 30% of all health care spending is wasted. To reduce unnecessary tests and procedures, physicians will need to play a leading role—their decisions account for about 80% of health care expenditures. Yet physicians do not always have the most current effectiveness data, and despite acting in good faith, they can recommend diagnostic or therapeutic interventions that are no longer considered essential. Also, research shows that physicians may need help communicating these matters to their patients. This may be especially difficult when clinicians and consumers are deluged with advertising and promotion. Clinicians often report feeling compelled to accommodate patients’ requests for interventions they know are unnecessary. At the same time, patients need trustworthy information to help them better understand that more care is not always better care, and in some cases can actually cause more harm than good. A major goal of health care reform is enhancing “patientcentered care.” Patients, and consumer groups representing them, express increasing interest in forging true partnerships with their clinicians, with real-time access to their own medical records, to science-based comparative effectiveness information, and to health care delivery environments built to enhance both comfort and personalization of medical care. Patient engagement, as 1 of the 6 major initiatives of the National Priorities Partnership of the National Quality Forum, promises more informed and involved patients as decision makers. To make good on this promise requires transparent and credible information about the relative value and risk of various medical diagnostic and therapeutic interventions. To help reduce waste in the US health care system and promote physician and patient conversations about making wise choices about treatments, 9 medical specialty societies have joined the ABIM (American Board of Internal Medicine) Foundation and Consumer Reports in the first phase of the Choosing Wisely campaign, including the following: American Academy of Allergy, Asthma & Immunology; American Academy of Family Physicians; American College of Cardiology; American College of Physicians; American College of Radiology; American Gastroenterological Association; American Society of Clinical Oncology; American Society of Nephrology; and the American Society of Nuclear Cardiology. As part of Choosing Wisely, each society has developed a list of 5 tests, treatments, or services that are commonly used in that specialty and for which the use should be reevaluated by patients and clinicians. Those lists were released on April 4, 2012, at a national event in Washington, DC. Additionally, other societies, consumer organizations, and physician organizations have asked how they can become part of this effort to engage physicians and patients in conversations about tests and procedures that should rarely be used. The early origins of this campaign can be found in “Medical Professionalism in the New Millennium: A Physician Charter.” Authored in 2002 by the ABIM Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine, the charter has as its fundamental principles the primacy of patient welfare, pa-

Redesigning Residency Training in Internal Medicine: The Consensus Report of the Alliance for Academic Internal Medicine Education Redesign Task Force

Because of numerous criticisms of the content and structure of residency training, redesigning graduate medical education (GME) has become a high priority for the internal medicine community. From 2005 to 2007, the leadership of the internal medicine community, working under the auspices of the Alliance for Academic Internal Medicine Education Redesign Task Force, developed six recommendations it will pursue to improve residency education: (1) focus education around a "core" of internal medicine, which provides the framework for both the structure and content of residents' educational experiences, (2) fully adopt competency-based evaluation and advancement, which will enhance training by focusing on individual learners' needs, (3) allow for increased, resident-centered education beyond the internal medicine core, because different types of practice require customized knowledge and skills, (4) improve ambulatory training by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities, (5) use new faculty models that emphasize the creation of a core faculty, and (6) align institutional and programmatic resources with the goals of redesign, balancing the clinical mission of the institution with the educational goals of residency training. Adoption of these recommendations will require significant efforts, including pilot projects, faculty development, changes in accreditation requirements, and modifications of GME funding systems. Opportunities are ample for individual programs to develop creative approaches based on the framework for educational redesign outlined in this article, and for these educational and clinical redesign initiatives to work hand-in-hand for the benefit of patients, faculty, trainees, and institutions.

Medical professionalism in the new millennium: a physician charter 15 months later.

Annals and The Lancet published the Charter on Medical Professionalism 15 months ago. This paper describes the rationale for the charter, provides an update on what has happened since initial publi...

Medical professionalism in the new millennium: a physician charter.

Medical professionalism in the new millennium: a physician charter.