Q & A with SGIM’s CEO and Past President on a Flashback Triggered by SGIM’s Update of Choosing Wisely Recommendations

SGIM: What came to mind when the American Board of Internal Medicine (ABIM) Foundation recently asked SGIM to update its Choosing Wisely recommendations?

Dr. Bass: I had a flashback to the firestorm that erupted when SGIM released the first version of its Choosing Wisely recommendations in 2013 when I was SGIM’s President.^{1, 2} I remember a standing room only town hall at the 2014 SGIM national meeting dedicated to discussing members’ concerns about the potential consequences of the recommendation initially worded as “don’t perform routine general health checks for asymptomatic patients.”³ At the town hall, David Himmelstein eloquently presented a critique of the studies most relevant to the topic. Subsequently, David joined Russell Phillips in publishing an article in the Annals of Internal Medicine entitled “Should we abandon routine visits? There is little evidence for or against.”⁴

SGIM: What did we learn from the vociferous debate about recommending against routine general health checks for asymptomatic adults?

Dr. Bass: Ultimately, the controversy reinforced the importance of physicians having conversations with patients that place evidence in the context of a humanistic approach to the doctor-patient relationship.² We agreed that the advice should not be used to withhold coverage for visits that are needed to establish a reliable relationship with a primary care clinician. As a result of the controversy, more attention was given to the importance of having an established relationship with a primary care clinician. Although that principle was not captured by the sound bite version of the recommendation, it was entirely consistent with the purpose of the Choosing Wisely initiative—to promote conversations between patients and their clinicians around tests and procedures whose necessity should be questioned and whose potential harms and benefits clarified within the context of each patient’s care plan.¹

SGIM: How have SGIM’s Choosing Wisely recommendations evolved since 2013?

Dr. Bass: When SGIM agreed to participate in the Choosing Wisely campaign at the beginning of my year as President, the Society formed an ad hoc committee to develop recommendations on five high-priority topics for academic general internists across the spectrum of their clinical practice. In addition to the recommendation against routine general health checks, the committee developed recommendations against use of daily home finger glucose testing in patients with type 2 diabetes mellitus not using insulin, routine preoperative testing before low-risk surgical procedures, cancer screening in adults with life-expectancy less than 10 years, and peripherally inserted central catheters for patient or provide convenience. None of those four recommendations generated any controversy.

In 2017, SGIM updated its Choosing Wisely recommendations after a new ad hoc committee reviewed recent evidence on each topic. The recommendation that changed the most was on annual health checks. The revised version stated that “for asymptomatic adults without a chronic medical condition, mental health problem, or other health concern, don’t routinely perform annual general health checks that include a comprehensive physical examination and lab testing. Adults should talk with a trusted doctor about how often they should be seen to maintain an effective doctor-patient relationship, attend to preventive care, and facilitate timely recognition of new problems.”⁵ This wording is notable for the emphasis on talking with a trusted doctor.

In 2021, the ABIM Foundation asked SGIM to update the recommendations again. SGIM formed another ad hoc group to review recent evidence and determine whether any of the recommendations should be revised or retired. Fortuitously, SGIM members had contributed to a recent systematic review on general health checks in adult primary care.⁶ Although new evidence was found on all of the topics, none of the recommendations required major revision, indicating that they have held up well over time. The biggest change in wording is on routine annual checkups—“Don’t perform routine annual checkups unless patients are likely to benefit; the frequency of checkups should be based on individual risk factors and preferences. During checkups, don’t conduct comprehensive physical exams or routine lab testing.”⁷

The latest wording does not explicitly refer to the doctor-patient relationship, but it is assumed in the emphasis on considering individual risk factors and preferences. It is difficult to capture pertinent nuances in the sound bite format that the ABIM Foundation prefers for all Choosing Wisely recommendations. The summary of the full version of the recommendation emphasizes that “patients who are likely to benefit from annual checkups include those who are overdue for recommended preventive care, at high risk of undiagnosed chronic illness, rarely see their primary care physician, have low self-rated health, or have a high degree of worry. Patients from historically excluded or marginalized groups, such as racial and ethnic minoritized groups and those with low income, are at increased risk of many health problems and are more likely to benefit from checkups.”⁷ A simple sound bite will never give enough emphasis to these critically important aspects of the issue. To achieve SGIM’s vision for a just system of care in which all people can achieve optimal health, we must reaffirm our commitment to building trustworthy relationships with all who need care.