We all have choices, many times less is more. Ask Moe Greene.

By  |  March 21, 2014 | 

by Dr. John Bulger DO, MBA

I am not Moe Greene, I am John Bulger, DO, MBA.  I am the Chief Quality Officer for the Geisinger Health System. Prior to that, I conceived and lead the hospitalist program for Geisinger Medical Center and eventually multiple programs within the Geisinger Health System. In 2012 I was lucky enough to work with a wonderful group of hospitalists and SHM staff to formulate SHM’s Adult Choosing Wisely Recommendations.  Several of us subsequently published an article in the Journal of Hospital Medicine (we also worked closely with the Pediatrics group) focused on the recommendations and the process.

I heed the lessons learned from the Godfather daily.  I am apparently not the only one as a Google search of the terms godfather and lessons nets over 2 million results.  There are many examples that could help one in Choosing Wisely®:  leave the gun, take the cannoli or don’t ever take sides against the family.  Since HM14 is being held in Las Vegas, I see it only fitting to highlight another choice, the choice of Moe Greene.

Moe Greene is a fictional character in the Godfather movies.  He is thought to be a loose representation of Bugsy Seigel who was had a dream of an entertainment empire in the deserts of Nevada.  That dream became Las Vegas, both for Bugsy and Moe.  The current Godfather, the head of the Corleone crime family Michael Corleone, comes to see Moe Greene in Las Vegas and offers to buy his casino.  Michael’s brother Fredo had been working with Moe in Las Vegas for some time.

What does this have to do with the ABIM Foundation’s Choosing Wisely® Campaign you ask?

The proposal from the Corleone family is much less than Moe Greene feels he or the casino is worth. It is the least expensive option that he has before him.  Moe, being a business man of sorts, chooses not to take Michael Corleone’s offer. Actually, he launches into a tirade against the mob boss suggesting that he is washed up, disparages his brother, among other insults. Later in the film, when Michael Corleone settles all family score, Moe Greene is assassinated. If you are interested in more detail, follow the earlier link. Suffice to say, Moe’s choice of more rather than less was not wise.

As hospitalists, we all have critical choices to make every day that impact our patients.  Many of them are life and death like Moe’s. Many offer the temptation of erroneously choosing more treatment.  The heart of the Choosing Wisely® campaign is that we should evaluate whether less is better. Less radiation, less alarms, less invasive monitoring, less medication – with overtreatment costing the US healthcare system over $200 billion annually, there is much work to do.

In Las Vegas, there will be several opportunities to discuss the Choosing Wisely® Campaign. Wednesday afternoon’s session (Choosing Wisely®:  The Obvious Choice is Not Always the Best Choice – Just Ask Moe Greene!) will focus on the campaign and SHM’s Choosing Wisely® recommendations with an eye toward action.  Yes, we will use the Godfather as a metaphor. I hope that each of you will come with your own stories of how you are Choosing Wisely in your practice and your hospital. Ialso  hope that we can make the recommendations come alive!

On Thursday morning (The ABIM Foundation Choosing Wisely® Campaign:  What Hospitalists Need to Know), I will offer a more general overview of the lists and their origins as well as discussing some of the recommendations from other medical societies which have participated in the campaign. As hospitalists, we are inpatient primary care physicians.  As such, almost all of the recommendations (and there are now over 150 sets of five) touch hospitalist practice.  I will also highlight an upcoming “competition” aimed at recognizing hospitalists who have implemented the Choosing Wisely™ recommendations in innovative ways.

A recent post from Daniel Wolfson on the ABIM Foundation’s Medical Professionalism Blog highlighted the power of the campaign and the power of sharing – both within our hospitals, with medical students and residents, and with each other.  It highlights Robert Fogerty, MD, MPH and his work with trainees at Yale-New Haven Hospital.  Simple discussions go a long way toward leading change.  I hope that we can share similar discussions in Las Vegas. Our collective “less is better” choices will help our patients immensely.

Hopefully we get out of Vegas with our eyes open to change…unlike Moe Greene.


DrJohn BulgerJohn B. Bulger, DO, MBA has been the Chief Quality Officer for the Geisinger Health System since 2011.  Dr. Bulger served until the spring of 2012 as Director of Geisinger’s Hospital Medicine Service Line. He founded Geisinger Medical Center’s hospitalist model in 1999 and lead the program’s development to include six hospitals and over 100 physicians and advanced practitioners.

Dr. Bulger serves on regional and national groups aimed at improving quality of care.  He was appointed by the Governor of Pennsylvania to serve on the Pennsylvania Patient Safety Authority and is a member of the Agency for Healthcare Research and Quality’s standing workgroup on evaluation of its Quality Indicators™.  He is a member of the National Quality Forum All-Cause Admissions and Readmissions Steering Committee for the All-Cause Admissions and Readmissions Endorsement Maintenance Project.  Dr. Bulger serves on the Society of Hospital Medicine’s (SHM) Healthcare Quality and Patient Safety.  He has lead SHM’s participation in the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign®.

He holds appointments as a Clinical Associate Professor of Medicine and Regional Assistant Dean at Philadelphia College of Osteopathic Medicine (PCOM) and an Associate Professor of Medicine at Temple University School of Medicine.  

Dr. Bulger is a senior fellow of the SHM and a fellow of the American College of Osteopathic Internists (ACOI), the American College of Physicians, and the Association of Osteopathic Directors and Medical Educators (AODME).  He holds leadership positions in many medical organizations and institutions.  He is the Secretary-Treasurer of the ACOI, is a past-president of the AODME and serves on PCOM’s board of trustees.

Dr. Bulger is a lifelong resident of Pennsylvania.  He is a graduate of Juniata College, PCOM, and the Pennsylvania State University.  His wife, Michele, also a Juniata and PCOM graduate, is a pediatrician and member of Geisinger’s faculty.  They reside in Danville, PA with their children Ethan, Ben, and Ava.

One Comment

  1. Casey Quinlan (@MightyCasey) March 21, 2014 at 9:26 am - Reply

    Terrific analogy. As we shift away from fee for service toward fee for value, a “less is more” approach will deliver the best care.

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