The Porridge Is Just Right: Choosing Wisely®

By Guest Post |  March 26, 2015 | 

by John B. Bulger, DO, MBA

It began in the spring of 2012. A small sub-group of the Society of Hospital Medicine’s (SHM) Hospital Quality and Patient Safety Committee (HQPS) was given the task of coming up with five test and treatments that hospitalists overuse. The pediatric hospitalist community was already hard at work (and quite far ahead) on their list. An adult list was needed. It was early June and five were required by August. Starting prolifically with 160 candidates, a mix of opinion and science, leadership and rank and file, rigor and pragmatism cut the list to five – really six, but we couldn’t figure out a way to present one of them in the ABIM required negative (avoid or don’t do) syntax.

From SHM board approval in August to the release in February of 2013, the lists waited out a Presidential election and other media cycles. Manuscripts were written to present both the processes and the evidence (these would be published in September). At HM 2013, I likened the choices posed by Choosing Wisely® with Indiana Jones choice for the Holy Grail. To save his father he must choose wisely. He does, choosing the common cup, not the fancy bejeweled chalice: less is better. At HM 2013 we offered a pre-course highlighting the recommendations and teaching hospitalists how to locally implement. We were on our way to changing the culture of medicine. This was easy for hospitalists who inherently championed the theme.

Fast forward to HM 2014, which was held in Las Vegas, the oasis in the desert, the dream of Moe Greene (or Ben Siegel). Moe had a choice: take less money from Michael Corleone than he thought his casino was worth, or be rubbed out by the Don. Moe chose poorly resulting in a rather abrupt ending. Hospitalists though showed that they were embracing the movement. This was highlighted by many of the RIV posters aimed at impacting the ten SHM recommendations, but also other society’s lists.

That brings us to the dawn of HM 2015. The Choosing Wisely® case competition feted eight wonderful examples of grassroots efforts to change the conversation to value. Hospitalists have taken center stage with teaching value-based care to residents, creating lists within their own hospitals, writing the formative book on teaching value-based care. We’ve seen proliferation of phrases such as “Lose the Tube,” “One is the New Two,” and “Think Twice, Stick Once.”

Since 2013, the Journal of Hospital Medicine has published 20 articles (including one ahead of print last week) with the key words “Choosing Wisely®.” The Journal is now starting a regular series highlighting Choosing Wisely® and hospitalists. A rough review of the 160 or so articles on PubMed reflects that 1 in 6 are about, by, or because of hospitalists and/or the SHM recommendations.

We have come a long way! I’d like to think that this was set up by the work of the HQPS Choosing Wisely® subcommittee three years ago…but I’m smarter than that. Hospitalists would have picked up this ball and ran with it no matter what we did in 2012. That is what hospitalists do!

My daughter is much the same way when she occasionally puts down her book and asks for a story before bed. She is happy with whatever story I choose, but one of her favorites is Goldilocks and the Three Bears. While I think most her joy comes from my stirring renditions of Mama, Papa, and Baby Bear, it may reflect Goldilocks’ skilled judgment. A danger (and sometimes criticism) of Choosing Wisely® is that it tips the scale toward withholding care. While I do not share this view, it is important to heed. The goal of hospitalists Choosing Wisely® is to inform the patients so that we (patients and hospitalists) can share in making a decision about the care that is “just right.” Like Goldilocks, together we balance hot and cold, high cost and low cost, suffering and comfort. To Baby Bear’s chagrin, it was always his stuff that was “just right.”


Bulger_John_14John B. Bulger, DO, MBA has been the Chief Quality Officer for the Geisinger Health System since 2011.  Prior to that he led Geisinger’s hospitalist program’s development to include six hospitals and over 100 physicians and advanced practitioners.

Dr. Bulger serves on the Society of Hospital Medicine’s (SHM) healthcare quality and patient safety committee and has helped lead SHM’s participation in the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign®.

He lives in Danville, PA with his wife Michele (a pediatrician) their children Ethan, Ben, and Ava (the Goldilocks aficionado).

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