More than any other feature, the physician’s fiduciary duty to patients defines medicine as a profession. It is this duty that binds patient and physician together in the moral activity that characterizes the patient-physician relationship. This duty also demands that the physician set aside his or her own beliefs and advancement in order to do what is in the patient’s best interest while upholding the patient’s confidentiality.
As Edmund Pellegrino and David Thomasma  explain, this duty—imposed by a patient’s trust that the physician will act on his behalf to improve his welfare—is the “moral center of medicine”:
The physician is understood to have special skills which he promises to use in the interests of the patient when that patient presents himself for care. The prime focus of the physician’s intention, therefore, is the good of the patient who presents himself here now—and not some distant patient, not even the good of society or the greatest good for the greatest number .
Without this duty of fidelity that binds the physician’s decisions and actions to the welfare of the patient, the patient is unable to trust the physician, the patient-physician relationship disintegrates, and the practice of medicine ceases to be a profession. This relationship does not take place in a hermetically sealed office, however, but in a larger social framework in which the physician has multiple, if not conflicting, obligations and responsibilities in addition to the primary role as healer .
Today, as the practice of medicine rapidly evolves, physicians face the difficult task of “making fair, prudent, cost-conscious decisions for care that meet the needs of individual patients and help to ensure the availability of health care to others” . One fundamental challenge confronts every practicing physician in America today: providing safe, effective, high-quality care to patients while also limiting the rising cost of health care and the use of limited resources.
Believing that unnecessary use of resources was a significant contributor to rising health care costs, the American Board of Internal Medicine (ABIM) Foundation launched a national multiyear initiative, Choosing Wisely, in 2012, to bring attention to the increasing waste of resources in the United States, “help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices” . The unique aspect of this campaign is that physicians and patients work together to develop treatment plans that are effective for the patients but are also efficient and promote the sustainable use of limited resources.
In particular, the Choosing Wisely initiative strives to promote conversations between physicians and patients that help “patients choose care that is: supported by evidence; not duplicative of other tests or procedures already received; free from harm; [and] truly necessary” . By conversing openly with patients, physicians avoid acting paternalistically or withholding diagnostic procedures or treatments. Thus, they avoid even the perception that they are trying to restrict care. They also work with patients to eliminate or limit costly interventions that might have little or no benefit for them .
The Choosing Wisely campaign is a component of the ABIM Foundation’s larger goal of promoting wise choices by clinicians that will “improve health care outcomes, provide patient-centered care that avoids unnecessary and even harmful interventions, and reduce the rapidly-expanding costs of the health care system” .
To help make the Choosing Wisely campaign as practical and widespread as possible, ABIM has partnered with specialty and consumer groups to provide resources to both practicing physicians and patients. Currently, close to 20 specialty societies have signed on to the campaign, including:
The American Academy of Allergy, Asthma, and Immunology
The American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
The American College of Physicians
American College of Radiology
The American Geriatrics Society
The American Society for Clinical Pathology
The Society of Hospital Medicine
The fundamental component of the campaign is that each participating specialty society has identified its own list of “Five Things Physicians and Patients Should Question’ that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation” . Every item on each list of five is a common procedure or treatment that is overused and thus can lead to waste of health care resources (and a higher cost of treatments and shortage of resources for others). Each recommendation is accompanied by a short explanation of why the specific diagnostic test or procedure should be “questioned” by the physician and patient; some provide ideas for possible alternative procedures. The overall goal for the lists is to encourage “physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm” .
In the list of “Five Things Physicians and Patients Should Question” compiled by the American Academy of Family Physicians, for example, one recommendation suggests not performing Pap smears on women younger than 21 or those who have had a noncancer-related hysterectomy because (a) “most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost,” and (b) “Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes” .
In addition to the lists developed by the specialty societies, Consumer Reports has worked with the societies to develop consumer-friendly summaries of the lists that can help patients better understand some of the basic tests and procedures that are commonly overused by physicians. These lists include: “Allergy tests: When you need them and when you don’t” , “How should you treat heartburn and GERD?” , and “When do you need antibiotics for sinusitis?” . Such lists not only help patients stay informed about common diagnostic procedures, they also encourage them to engage in dialogues with their physicians about their health concerns and devise “wise treatment decisions” that work for patients like them, aren’t duplicative or harmful, and are “truly necessary” . Above all, the more that patients and physicians work together to discuss effective and responsible treatment decisions, the more they can build trusting, deliberative relationships—which ideally result in improved health outcomes for patients and more responsible use of limited health care resources.
While the ABIM Foundation’s Choosing Wisely campaign provides a useful way for physicians to engage their patients in open dialogues about their health and the most effective and efficient treatment options for their unique medical needs and goals, it is only the first step in the delicate balance all physicians must maintain between their fiduciary duty to their patients and their duty to be responsible stewards of limited health care resources.
It is imperative for today’s physicians to find an “equilibration” among their various professional loyalties and commitments so they can fulfill their primary obligation as healers while also being stewards, patient advocates, and scientists. Every physician’s “efforts in individual and personal medical transactions must be reinforced by a context of moral policy decisions which also attempts to reach some equilibrium between the inherent tensions of the canons of morality and economics” . As it expands and becomes more widely adopted and implemented, the ABIM Foundation’s Choosing Wisely campaign serves as a vital resource for physicians in meeting the challenge of providing safe, effective, high-quality, and sustainable care.
Pellegrino ED, Thomasma, DC. A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Professions. New York: Oxford University Press; 1981.
Pellegrino, Thomasma, 269.
American Medical Association Council on Ethical and Judicial Affairs. CEHA Report 1-A-12: Physician stewardship of health care resources [adopted June 2012]. http://www.ama-assn.org/resources/doc/ethics/ceja-1a12.pdf. Accessed October 10, 2012.
Choosing Wisely. The Choosing Wisely campaign: five things physicians and patients should question. http://choosingwisely.org/wp-content/uploads/2011/12/about_choosingwisely.pdf. Accessed October 10, 2012.
ABIM Foundation. Choosing Wisely web site. http://choosingwisely.org. Accessed October 10, 2012.
Consumer Health Choices. Campaign: Choosing Wisely: educating consumers about appropriate care. http://consumerhealthchoices.org/campaigns/choosing-wisely. Accessed October 10, 2012.
Choosing Wisely. American Academy of Family Physicians: five things physicians and patients should question. http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Acad_Fam_Phys.pdf. Accessed October 10, 2012.
Choosing Wisely. Allergy tests: when you need them—and when you don’t. http://consumerhealthchoices.org/wp-content/uploads/2012/07/ChoosingWiselyAllergyTestsAAAAI.pdf. Accessed October 10, 2012.
Choosing Wisely. Treating heartburn and GERD. http://consumerhealthchoices.org/wp-content/uploads/2012/05/ChoosingWiselyHeartburnAGA2.pdf. Accessed October 10, 2012.
Choosing Wisely. Treating sinusitis: don’t rush to antibiotics. http://consumerhealthchoices.org/wp-content/uploads/2012/04/ChoosingWiselySinusitusAAAAI.pdf. Accessed October 10, 2012.
Pellegrino, Thomasma, 280.