I learnt about Choosing Wisely in the USA from reporting at its inception and followed its progress with great interest. It was a project to prod physicians and healthcare consumers to avoid low value, potentially harmful interventions. Beginning in 2012, over 80 organisations of medical specialists created lists of the most common procedures whose necessity should be questioned. Backing up the lists were materials ‘to help patients engage their healthcare provider in these conversations and empower them to ask questions about what tests and procedures are right for them…’.

I saw the project primarily as an empowerment tool for consumers. To me, Choosing Wisely was all about patient autonomy. But then, to people who know me, pretty much everything is about patient autonomy.

But it wasn’t until I tried to use it myself that I learnt about some of the obstacles to its use. Choosing Wisely was an exciting project, but one whose success was extremely modest. Why did it not have more of an impact?

To partially answer this question, here is my experience as a patient with trying to use Choosing Wisely to avoid low-value care. Trying being the operative word here.

Five years ago, I needed to have cataract surgery. Because of an underlying condition in the relevant eye, I needed to see a specialist surgeon. My appointment with him included a clear explanation of the procedure, the risks and the benefits and included adequate time for questions. After many tests, I was decanted into the office of the scheduler, who gave me an appointment for surgery 3 months later. She also told me to make an appointment with my primary care physician for an ECG, a test to check for heart conditions.

Looking at the Choosing Wisely website the next day, I immediately realised that I should have questioned the need for an ECG. But when I tried to call the surgeon to have the ‘conversation’, Choosing Wisely was founded to support, I was stymied at every turn. His office would not allow me to speak with him when they found out what I was calling about; ECGs were ‘routine’, and therefore, it was pointless for me to discuss it. The receptionist even told me (erroneously) that they were required by state law. I enlisted my primary care physician, a wonderful woman committed to evidence based medicine. She tried to call the surgeon; she was also stonewalled. At this same time, the American Academy of Ophthalmology’s website featured this very issue, emphasising that routine ECGs are not recommended, urging patients to have a conversation with their physician to discuss if preoperative tests are important based on their own particular history. But how can I have a conversation if the surgeon doesn’t even know I am trying to call?

I resorted to the mail, marking the envelope ‘Personal,’ and including printouts of the AAO website and supporting articles. I got a phone message from the surgeon, validating my concern but regretting that the surgery centre he uses would not allow him to operate without the ECG. The surgeon blamed the anaesthetists; my primary care physician, now on a mission, called them as well but got nowhere.

By now, 2 months had gone by. Should I jettison the time and money I had already spent and start over again, finding a different surgeon in a different city? Or should I subject myself to an unnecessary ECG, courting the possibility of a diagnostic cascade that could lead to risky, unnecessary, invasive procedures? In the end, I showed up at my primary care physician’s office, and we ruefully went through the charade of the ECG (which, of course, my insurance company happily paid for).

So where did Choosing Wisely get me? I ended up feeling adversarial and angry with someone who was about to put sharp objects in my eye. Not a helpful outcome. To rub salt in the wound, there is a slightly condescending air to much of the rhetoric surrounding Choosing Wisely, as if it is we—poor, misguided, anxious patients—who are pressuring doctors for unnecessary procedures. ‘If patients are worried that they have heart disease and haven't gotten a recent EKG, part of it is explaining to patients why more is not always better.’ How about explaining that to physicians?

The Choosing Wisely campaign ended in the USA in 2023 (Choosing Wisely in other parts of the world remains very active). My experience highlights barriers that need to be addressed if a successor to Choosing Wisely can realise its potential. For example, it is relatively easy to get questions answered when one is actually in the physician’s office. Later, however, it is extremely difficult to communicate with the physician, and yet that is when many of one’s questions arise. Should patients routinely bring the relevant Choosing Wisely list to every appointment? Wouldn’t that look odd or vaguely hostile and signal to the doctor that one is a ‘problem patient’?

Choosing Wisely was both modern and old-fashioned. Modern in that it embraced the patient as an internet-savvy consumer. But old-fashioned in that it imagined a dyadic ‘doctor–patient relationship’ that ignored realities of how the office is run, how care is influenced by billing, the problem of defensive medicine, etc. Few people have a direct relationship with their doctor today. They have a ‘relationship’ with a health network and with an army including secretaries, nurses and schedulers, among others, who create a bureaucratic fence between doctor and patient. I now routinely ask a physician, ‘How can I reach you directly if I have additional questions?’

The Choosing Wisely website contained great resources for physicians, including videos demonstrating key elements of communication, all within the context of avoiding unnecessary care. But all the videos assumed that it was the patient asking for the treatment and the doctor who explains why it is unnecessary. How about modules to support patients in talking with their physicians? Or just getting their physicians to pick up the phone!

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