New post up at Medscape/Cardiology — Heart Rhythm Society’s Choosing Wisely List is tentative and cursory

The Choosing Wisely campaign began in 2009 when the American Board of Internal Medicine (ABIM) Foundation invited medical societies to own their role as “stewards of finite healthcare resources.”  The movement aims to promote care that is supported by evidence, not duplicative, free from harm and truly necessary. That sounds delightful, and I wrote enthusiastically about Choosing Wisely back in 2012.

It appeals to me because it addresses core problems in US Healthcare–inefficiency, excessive action and paternalism. While Choosing wisely informs patients, it targets doctors to do their part in stopping the madness–of overtesting, overdiagnosing and overtreating. Choosing Wisely is special because it comes from doctors not policy wonks or third-party payers.

It felt strange to me that the Heart Rhythm Society waited so long to release their list of 5 Don’ts. Why was this?  The optimist in me had hoped that the delay meant HRS leadership was working hard at designing a meaningful and robust list. A recent New England Journal of Medicine Perspective piece made it clear that while some medical societies looked inward and made tough calls ( American College of Cardiology), others phoned it in ( American Academy of Orthopaedic Surgeons)^.

A Choosing Wisely list from HRS is important because of the nature of electrophysiology. Heart-rhythm therapies are no small thing. Our interventions are big, expensive, and almost always preference sensitive. These are therapies that may provide great benefit but also come with significant burden. It’s one thing to overuse pink-eye treatments, it’s another to overuse shocking devices, catheter ablation, or antiarrhythmic drugs.

Finally, this week, HRS released their list of “Five Things Physicians and Patients Should Question^.”

I didn’t like the list at all. Some recommendations left out important details, others stated the obvious, and two bordered on insulting. What a lost opportunity for leadership.

Now what? How can I be critical of the Heart Rhythm Society? These are smart and accomplished people. Dr Hugh Caulkins from John Hopkins is HRS president. One time, early in my AF ablation experience, I called him to ask a question about a patient problem. He didn’t know me but took the time to take my call. On the phone he was kind, patient and useful. Dr. Rich Fogel from Indianapolis is president-elect. I worked with Rich when I moonlighted during fellowship. He’s a great guy. He cares. Others on the list of HRS leadership, I haven’t met, but I respect their work.

It’s not easy to be critical of this group. That said, opinion commentary is my job description over Medscape Cardiology–the old theHeart.org.

My post is 2200 words. In part 1, I give a letter grade to each of the 5 HRS Choosing Wisely lists. The commentary gets into technical medical issues but the theme is that the list was cursory and tentative. In part 2 of the post, I suggest more worthy items for an electrophysiology list. These include, paying more attention to the ICD generator change, increasing the shared decision-making process in ICD decisions, cutting back on overtreatment of atrial fibrillation, especially in the elderly and a host of other “littler things.”

One more teaser: I’ll give you my conclusion:

One of the reasons I was drawn to cardiology as a young learner was that we were leaders. I saw cardiologists as bold and courageous. We led the medical community in clinical science. We did not back down from challenges.

In another era, the challenge of medicine was finding better treatments of acquired heart disease. It wasn’t long ago that patients with MI were treated with bed rest and opiates. We’ve come a long way. We’ve done a lot.

But these are different times—with different challenges.

The challenge for medical doctors and their societies now is not about delivering more medicine and surgery; it’s about using our many tools wisely and aligning them with our patient’s goals.

The game has changed. Can we?

I hope you want to read the entire post. The title of it is Heart Rhythm Society’s Choosing Wisely List Disappoints

JMM