Table 2.
Domain | Justification and Considerations |
---|---|
Quality improvement/peer review | Include cases in morbidity and mortality conferences with adverse outcomes or unnecessary admissions caused by overtesting. Administrators advocate and support physicians who tolerate uncertainty when decisionmaking is challenged by consultants and admitting physicians (eg, formal endorsement of Choosing Wisely recommendations by department/hospital leadership and risk management). Promote a culture in which ED decisions are not criticized retrospectively according to information that becomes available after the ED visit. |
Patient care metrics | Assess adequacy of shared decisionmaking as part of patient satisfaction surveys. Use audit and feedback physician resources, particularly for advanced imaging and admissions, including Choosing Wisely measures. Eliminate ED returns as an adverse event metric, or qualify this metric according to whether the decisionmaking for the initial visit was within the standard of care. |
Work flows | Support alternative care pathways for patients who would likely benefit from observation rather than additional testing. Facilitate efficient physician access to evidence-based clinical decision support. Use joint education of physician and nursing staff in regard to thresholds for testing and admission to reduce occurrences of inconsistent and discrepant patient communication on these issues. |
Professional societies | Emergency medicine organizations advocate didactic sessions and training on tolerance of uncertainty. Participate in an annual conference about preventing overdiagnosis. Prioritize additional research on acceptable risk thresholds for both patients and physicians. Disseminate guidelines that identify clinical scenarios in which there are multiple acceptable approaches because of uncertain risks/benefits. Work with lawyers and judges to better define the liability of physicians who miss a diagnosis as a result of a decision not to perform a diagnostic test that, at the time, was considered to have a very low likelihood of having a positive result. |