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An Illusory Freedom of Choice

By Dr Pramita Kuruvilla

As Americans, we are surrounded by multiple options in most aspects of our lives:  Twenty varieties of boxed cereals line grocery store shelves, rows of shiny cars in a rainbow of colors, three new iPad versions and plenty more on eBay, and so it goes.  On the surface at least, health care options are just as plentiful and abundant: anybody on US soil is confronted by an array of medical options unheard of elsewhere in the world.   

Is more truly better?  Heaven forbid that we should mention …shhh...rationing…  Stop!  Not a permitted word!  Images of impassioned politicians (fighting for YOUR freedom) and fiery political rhetoric immediately spring to mind (death panels, anyone?).  How dare anyone suggest limiting our choices in our most intimate health needs?!  However, as health professionals already know, the grim reality is that our nation’s choices are already being limited, manipulated, and marketed, often by nonmedical forces. 

Let’s order an MRI for that back pain that started last week because you need it… or (most common) because you are insistent and I have neither time nor energy to argue about how unnecessary it is… or (more unusual but still present) because I fear a lawsuit for a rare and unlikely diagnosis… or (more cynical and thankfully quite rare) because I am part owner in the local imaging group…

The “Choosing Wisely” initiative is a welcome relief from the excessive waste that has infiltrated all levels of our national health infrastructure.  Led by the American Board of Internal Medicine Foundation, the campaign’s aims are to promote discussion about choices that are supported by evidence, not duplicative of other tests of procedures already received, free from harm, and truly necessary.  Nine specialty societies have already risen to the challenge and identified lists of the top five things that warrant patient-doctor discussion in their specialty, e.g. when to use antibiotics for acute sinusitis or when to order imaging for headaches.  Such a broad multispecialty campaign is powerful in advocating for truly excellent health care choices for the entire nation. 

U.S. healthcare presents itself as being an open forum for informed consent, patient autonomy, and shared-decision-making models, but it often ends up being a prison of too many options, too little realistic information sharing, and too much fear of litigation to allow for honest discussions of the magical thinking many patients, families, and doctors believe.  Until there is a nationalized health system with quality outcomes-based protocols, individuals will be faced with paralyzing decisions and will never have true freedom to know that they were offered the best advice that their money could buy… At least now, the Choosing Wisely initiative is a good place to start.

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