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Atul Gawande’s Lessons for Choosing Wisely®

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I read Atul Gawande’s recent article in The New Yorker (07.29.13), “Slow Ideas,” with great interest. In it, Gawande asks, “Why do some innovations spread so swiftly and others so slowly?” I immediately harkened back to the Choosing Wisely campaign.

Through multiple examples of ideas that caught on—and others that didn’t—Gawande makes several salient points that should be considered when discussing how to implement the Choosing Wisely recommendations on the ground. Among them:

While referring to ways the status quo was changed for childbirth practices in developing countries or hand-washing practices in the USA in the 1800s, Gawande notes: (N)either penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching.”

My hope is that through Choosing Wisely, we develop a culture and a new norm of intolerance of wasteful tests and procedures. That culture would be developed by conversations among physicians about the altruistic reasons they entered the profession, rather than the financial ones, and the new “norm” would be not ordering a test rather than automatically ordering one.

As Everett Rogers, author of Diffusion of Innovations, showed, people follow the lead of other people they know and trust when adopting an innovation.

The success of Choosing Wisely has largely been through the leadership and of the specialty societies and the respect physicians on the ground have for them. It is not only in each society partner’s identification of tests and procedures but the strong signal they sent through their partnership, that physicians should be concerned about waste in the system as a quality and safety issue.

“We yearn for frictionless, technological solutions. But people talking to people is still the way that norms and standards change.”

In his piece, Gawande relays a story in which health care has been changed by high-touch solutions like local women talking to mothers about pregnancy and care of infants in developing countries. Easy-to-follow messages relayed on a person-to-person basis had more impact than official mandates and regulations. Through a grant from Robert Wood Johnson Foundation, Choosing Wisely has funded 21 sites to promote such one-on-one conversations among physicians and between patients and physicians. It’s these conversations that are the important catalysts for change in both attitudes and norms in ordering tests and procedures without clear purpose.

After a mere 16 months since the first nine lists of recommendations were released, skeptics of Choosing Wisely are asking if utilization of these services has changed. What is important is that these conversations have begun and have been initiated in some measure by this campaign. More and more motivated delivery systems are needed to support these conversations and they need personnel on the ground to have these one-on-one interactions. This is in addition to providing  systems support (e.g., clinical decision support, feedback on compliance, continuing education and financial and non-financial incentives) to add to the efforts to produce  desired behavioral changes.

Changes in the environment will hopefully shorten the adoption phase but there is no skimping on the need for cultural and norm changes.


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