Shocking Lack of Obedience by Steven Vaughn MD, PhD


One of our largest Healthcare Corporations has used its house journal, the JAMA, to publish its findings on the stubborn disobedience by primary care individuals in obeying ‘guidelines’ for ‘choosing wisely.’

For this population-level analysis of 7 low-value services analyzed, changes were modest but showed a desirable decrease for 2 recommendations (imaging for headache, cardiac imaging for low-risk patients). The effect sizes were marginal, however, and although 4 of the 7 lists had statistically significant changes—unsurprising given the large sample size—the clinical significance is uncertain. These results suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations.

The kicker is the very last sentence – when gentle approaches fail, it’s time to get out the iron fist.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  8 comments for “Shocking Lack of Obedience by Steven Vaughn MD, PhD

  1. Bridget Reidy MD
    October 23, 2015 at 3:05 am

    Choosing Wisely, Beer’s list and so on are wonderful tools to get patients on board with understanding more can be less, and less can be more, a very counter cultural notion. They are written in lay language because they are meant to educate the public. They free us from suspicious patients, and are not meant to confine us, despite what JAMA says.

    If I say in essence “When the American Geriatric Society had to choose five things they wanted to see less of, treating a germ in the bladder that doesn’t explain your symptoms was one of them because so many people believe as you do that UTI’s can cause any symptom, and antibiotics are causing harm, never mind the harm that’s done from stopping looking for the real cause of your symptoms”- it always works with patients and family caregivers. Before that my frail patients and families often couldn’t be convinced even after the antibiotic didn’t work as expected, even if I’d say things like “geriatricians say a fluctuating level of consciousness is medication related until proven otherwise” (that being the symptom that most often leads to treatment of asymptomatic bacteruria in my experience).

    But neither of these approaches works on other geriatric professionals including nurses, aides, social workers and therapists, – unless they know me well. I agree these directives need to go more to the public and those who pressure doctors. Maybe the reason they don’t change our practice is because we are often already practicing that way, when appropriate and when not overly pressured. They do succeed in making our job easier and increasing patient trust in us when we do less than expected, and that’s no small thing. And culture can change though it is usually very slow.

  2. Mamadoc
    October 22, 2015 at 11:02 pm

    I once told a quality team that they could look after the protocol all they wanted but I would look after the patient and that I wasn’t especially interested in what they thought about it 6 months after the fact. I got into a LOT of trouble. “Additional interventions,” indeed.

  3. Randy
    October 18, 2015 at 10:23 am

    In general I agree with the concept and recommendations of the Choosing Wisely campaign, but just proclaiming that these are going to be the new guidelines is not enough. Until there is tort reform there are going to be CYA studies ordered. Many professional organizations still use a different set of guidelines than the USPSTF, making some of the Choosing Wisely recommendations open to debate. Add to that the “more is better” mindset of the public has to change.

    In order to make real progress the rest of society has to get on board with the recommendations. That includes the government, the legal system, the professional organizations and the charitable organizations in addition to physicians.

  4. Bill Ameen MD
    October 18, 2015 at 9:59 am

    Did PCPs whose “trends” were examined know they were being examined? And, if so, were they exempt from patient satisfaction questionnaires? That said, all these ‘interventions” are common sense that are taught in medical school and in the most basic CME. How many times do I read, don’t use antibiotics in most sinusitis and don’t Xray backs on the first visit? (Of course, chiropractors do, and to the best of my knowledge they have no one looking over their shoulders.)

    • Steve O'
      October 18, 2015 at 12:28 pm

      I brought a patient back to see me. He was infuriated that I did not give him antibiotics for his frequently recurring sinusitis. Many others have. After seeing me on the last visit, he went to a Quickie-Stop ‘clinic’ at a national retail drugstore, and got his antibiotic – and albuterol, for what, I don’t know.
      I discussed the sinus CT which I ordered, that showed a complex mass of gluey dried mucus, small bubbles of bacterial gas, and other horrors. I sent him to ENT to have that nasal dumpster cleaned out. He, of course, complained about his care to the advocacy center. His complaint was not that his stubbornness and others’ compliance led to this awful grotesque thing. Rather, he complained that I did not give him a Z-Pak.
      Is “choosing wisely” just a case of unthinking obedience to the rule du jour?

      • Bill Ameen MD
        October 18, 2015 at 3:09 pm

        What’s left out of the Choosing Wisely study is educating patients BEFORE they come to us, but that’s a virtual impossibility. That may be the only good function of a telemedicine intervention. Stay the hell away from doctors…that’ll drop the nation’s health tab. But with all the competition from Quickie clinics, freestanding NPs, and specialists doing primary care, who’s going to tell patients to stay away?? With gross underpayment by Medicare, Medicaid, and insurance, doctors have to cram in everybody they can…unless they follow Dr. Doug’s model!

  5. Pat
    October 18, 2015 at 9:56 am

    No kidding, that was a chilling last sentence.

    • Perry
      October 18, 2015 at 12:12 pm

      Addtional interventions like….
      Being drawn and quartered?
      Scary indeed.

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