Issue 7 / 2 March 2015

YOU might have heard some buzz recently about next month’s planned launch by NPS MedicineWise, of the Choosing Wisely Australia initiative.

The idea that some routine health care practices provide little benefit and possibly harm patients and are overused, misused or wasteful has been around for a while. There has been more than a decade of similar work in the UK by the National Institute for Clinical Excellence in identifying low value health care practices. The Australian initiative is based on a US program.

Most health care workers could think of examples of potentially low-value practices but the specifics (and any moves to disinvestment) can be controversial, as the MJA editors discovered when we published a study in 2012, that flagged 150 practices currently funded via the Medicare Benefits Schedule for further investigation of their utility.

The study provoked robust responses defending some of the practices and others in support of the researchers’ findings: the kind of discussion it was surely designed to foster.

As revealed in one of our news stories this week, the Australian iteration of Choosing Wisely has something big going for it. Rather than taking a top-down approach, the organisers have asked the medical colleges to use their own processes to produce an initial list of five practices each, that providers and consumers should question.

As Dr Justin Colemen, chair of the RACGP working group for the initiative, told MJA InSight: “Doctors are more likely to act on the recommendation if they feel that they genuinely came from a wide number of their peers”.

For those wanting a sneak preview, Dr Coleman has published the RACGP’s short list on his blog.

The concept of doctors and patients empowered to make a multitude of individual wise choices about best practice is wonderful, but many influential choices about health care happen at a higher level.

InSight’s lead news story this week explores the plight of employees and clients of non-government organisations with mental health programs. These organisations are currently uncertain about what services they will be able to offer after June this year, as they await advice from the federal government on whether their funding will continue.

The government’s decision on which services to fund rests on their response to a review of the effectiveness of existing programs by the National Mental Health Commission, including gaps and duplications.

Like the Choosing Wisely initiative, these larger-scale choices need to have health improvement at their heart.

Mental health epidemiologist Professor Anthony Jorm told MJA InSight there was indeed room for the elimination of duplication in mental health services but that the commission’s report should not be seen as an “excuse to cut costs rather than make a long-term plan for improving the situation”.

While governments make choices for patients, decisions by health care workers on the ground are made with patients. The familiar question “What would you do doctor?” lurks in the background in even the most dispassionate of therapeutic discussions.

While answering that question is not always a good idea, failing to acknowledge the request for support that lies behind it also does nobody any favours.

In her blog this week, Jane McCredie highlights an interesting paper in the Journal of Medical Ethics that makes the distinction between providing “neutral” and “balanced” information to parents who are faced with making choices about life-sustaining treatment for their seriously ill or dying child.

These sorts of discussions put the concept of choosing wisely in a whole new light. They underscore the need for us all to come to terms with how we can share decisions with patients in situations where the wisest of choices might still lead to a devastating outcome.

Thankfully, clinical practice is mostly made up of more prosaic choices and, in modern medicine’s simple quest for choosing wisely by doing less, it seems we are in good company.

“To attain knowledge, add things every day. To attain wisdom, remove things every day” — Lao Tzu (604 BC-531 BC) Chinese Taoist philosopher

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

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