Physician Perceptions of Choosing Wisely and Drivers of Overuse

The authors surveyed physicians regarding “Choosing Wisely” and hypothesized drivers of overuse, finding high reported prevalence of hypothesized drivers of overuse and widespread support for cost-consciousness.
Published Online: May 17, 2016
Carrie H. Colla, PhD; Elizabeth A. Kinsella, BA; Nancy E. Morden, MD, MPH; David J. Meyers, MPH; Meredith B. Rosenthal, PhD; and Thomas D. Sequist, MD, MPH


Objectives: Little is known regarding physicians’ views on health service overuse or their awareness of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. Through the Survey on Overuse and Knowledge of Choosing Wisely, we assessed physician views on hypothesized drivers of overuse and Choosing Wisely.

Study Design: We designed the survey to investigate physicians’ knowledge of, awareness of, and feelings toward Choosing Wisely, along with their concerns about malpractice, perception of patient demand, discomfort with uncertainty, and cost-consciousness. Where possible, we used pre-validated survey instruments.

Methods: We distributed the survey to clinicians practicing at Atrius Health, the largest ambulatory care provider in Massachusetts. We analyzed 584 responses (72% response rate) and calculated 3 previously validated scales.

Results: Primary care physicians reported significantly greater awareness of Choosing Wisely (47.2%) than medical specialists (37.4%) and surgical specialists (27%). A majority (62%) of all respondents reported they found uncertainty involved in providing care disconcerting. Approximately one-third felt it unfair to ask physicians to be both cost-conscious and concerned with welfare, thought too much emphasis was placed on costs, and thought doctors were too busy to worry about costs. Surgical specialists were more concerned about malpractice, whereas primary care physicians reported feeling significantly more pressure from patients for tests and procedures.

Conclusions: Knowledge of Choosing Wisely is limited, but primary care physicians are more aware of the campaign than specialists. Although hypothesized drivers of overuse are prevalent, most physicians support cost-consciousness in medicine and embrace their responsibility in reducing costs.

Am J Manag Care. 2016;22(5):337-343

Take-Away Points
Our analysis presents findings that can be used to inform practice and policy:
  • Initiatives aimed at improving financial stewardship may benefit from efforts targeted at supporting clinicians in dealing with the uncertainty that comes with conservative management. Physicians may be more willing to forgo or delay low-value care if they have appropriate support that addresses patient demand, malpractice concerns, and other drivers of overuse. 
  • There is receptivity to more support for physicians to consider costs when recommending testing or treatment regimens. Ideally, decision support would be combined with information on price to address the significant knowledge gap around costs expressed in our survey.
The overuse of healthcare services is receiving attention as physicians are increasingly asked to embrace financial stewardship and payment reform pushes provider groups to consider value. In the past, there was little agreement on classification of services as low-value and no consensus on which mechanisms were most effective in reducing the use of these low-value services.1 Aimed at filling this gap, “Choosing Wisely” is an effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite healthcare resources.2

Beginning in 2012, specialty societies partnered with the ABIM Foundation to create and publish lists of “Five Things Physicians and Patients Should Question”—evidence-based recommendations that should be discussed to help make wise decisions about appropriate care based on a patient’s individual situation. More than 70 specialty societies have joined the campaign and published lists, but the services on the lists are chosen by representatives from specialty societies, and wide participation is often not sought in their creation.3 This approach makes the level of awareness, acceptance, and adoption of the recommendations uncertain.

The impact of the Choosing Wisely initiative on low-value care depends on effective dissemination and uptake of the lists; understanding the drivers of overuse is also needed to inform interventions targeting these services. A suite of communication education modules is available through the ABIM Foundation to help providers engage in conversations with patients,4 and a small library of video resources is available on the Choosing Wisely website. State medical societies, specialty societies, and regional health collaboratives are helping extend the reach of the campaign in communities, and Consumer Reports is developing and disseminating materials to educate patients regarding the services targeted by Choosing Wisely.

Hypothesized drivers of health services overuse include discomfort with uncertainty (around diagnosis, for example), patient demand for services, fear of malpractice, and, perhaps most importantly, financial incentives that do not support cost-consciousness.5,6 Each of these requires a unique set of policy interventions to reduce overuse, and each may affect physicians and services in different ways. Understanding which of these factors physicians consider influential to their behavior regarding low-value services is key to the development of effective interventions.

The Choosing Wisely measures were developed by professional societies and appear to have gained credibility among a variety of stakeholders, but little is known about how widely the initiative is recognized among physicians. To maximize the influence of Choosing Wisely on the behavior of physicians, we must understand more about factors that lead to overuse of medical tests and procedures and how receptive physicians are to incorporating value-based decision making into their practice. In this paper, we report results from a survey of physicians at a large physician group practice regarding their awareness of, and feelings toward, the Choosing Wisely campaign and other hypothesized predictors of overuse, as well as their receptiveness to value-based decision making.

Survey Collection

Atrius Health is the largest ambulatory care provider in Massachusetts, providing outpatient primary and specialty care for nearly 1 million patients. They are also a Pioneer Medicare accountable care organization with a mix of fee-for-service and capitated contracts. In January 2014, we sent a cover letter detailing the purpose of the survey and the survey instrument to all clinicians (MD or DO) practicing at Atrius Health from Atrius staff and study team members. Second and third mailings, coupled with reminder e-mails, were sent to nonresponders at 3-week intervals. We distributed the survey to 808 clinicians and received 584 responses (72% response rate) by April 2014.

Survey Instrument

The 29-item Survey on Overuse and Knowledge of Choosing Wisely was designed to investigate whether overuse is impacted by a physician’s: 1) level of cost-consciousness, 2) comfort with clinical uncertainty, 3) concerns regarding malpractice, and 4) perceived pressure from patients and the healthcare system. The survey questions used for each scale are noted in Table 1. Where possible, we used validated survey instruments to examine potential determinants of overuse.

The Cost-Consciousness Scale, developed by Tilburt et al,7 was designed to assess how cost-conscious physicians are in their day-to-day care. It was calculated as a summation of 11 survey questions, with an answer of “strongly agree” equaling 4 and an answer of “strongly disagree” equaling 1. The composite score was on a scale of 11 to 44, with 44 representing the highest reported consciousness of cost.

The Discomfort With Uncertainty Scale, originally developed by Gerrity et al,8 sought to assess how uncomfortable physicians were in providing care for their patients when a diagnosis or follow-up care is uncertain. Previous studies have shortened the original 13-item Discomfort With Uncertainty Scale and demonstrated predictive validity with the abbreviated versions.9 Like Tilburt et al,7 we included 1 item from this tool to scale discomfort while decreasing redundancy for survey respondents. The response scale ranges from 1 to 4, with 4 indicating the highest level of discomfort.

The 5-item Malpractice Concerns Scale, a validated set of questions demonstrated to be associated with resource utilization,10,11 aimed to assess day-to-day malpractice concerns of physicians using 5 survey questions. We computed the percentage of responses either “strongly” or “moderately” agreeing with the provided statement, and the percentage for each question amounted to 20% of a final Malpractice Concerns composite score on a scale of 0 to 100.

Finally, we developed several new items, including questions addressing physicians’ perceived pressure from patients and the healthcare system to order tests and procedures, physicians’ attitudes toward making referrals, and physicians’ awareness of and views on the Choosing Wisely campaign. All questions—except for the 3 directly addressing Choosing Wisely—were presented as statements with a 4-point Likert scale, where possible responses ranged from “strongly agree” to “strongly disagree”; there was no neutral “neither agree nor disagree” option. Finally, 2 questions on years of practice and weekly clinical effort were included at the end of the survey (our sample included gender and specialty). Our survey instrument (see eAppendix 1 [eAppendices available at]) was approved by the Partners Health Care Human Studies Committee.

Respondent Characteristics

We calculated summary statistics for the Atrius population of physicians, the survey sample, and the US population of physicians. We used z tests of proportion to test if our sample differed significantly from national physician characteristic proportions and from that of Atrius as a whole.


We calculated summary statistics for each survey item and each scale. We adjusted the means of each calculated scale for age, gender, and clinical effort (half-sessions worked per week) using a linear regression model and average marginal effects. For the questions about knowledge of the Choosing Wisely program, we adjusted the proportions of responses for age, gender, and half-sessions worked per week using logistic and ordinal logistic models and average marginal effects. These covariates were included because the literature has demonstrated an association between age, gender, and clinical effort with hypothesized drivers of overuse, and we wanted to control for the potential impact of these differences on perceptions of Choosing Wisely.7-9

We used analysis of variance (ANOVA) to determine if there were significant differences in adjusted scale results between respondents in primary care, in medical specialties, and in surgical specialties.12,13 We used a logistic model and average marginal effects to calculate the predicted percent that agreed or strongly agreed, adjusted for years in practice, gender, and clinical effort. We tested the difference across specialties from these adjusted percentages using χ2 tests. We used the same method to additionally determine if there was: a) a significant difference across specialties in adjusted awareness of the Choosing Wisely campaign, b) if physicians viewed the Choosing Wisely campaign as a legitimate source of guidance, and c) if the campaign had empowered respondents to reduce the use of unnecessary tests and procedures. Finally, we reported correlations between the calculated scales and awareness of Choosing Wisely and attitudes toward being a steward of resources.


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