Internist Applies Choosing Wisely as Reinforcement for Patients' Concerns

Lisa Ehrlich, MD, uses the Choosing Wisely® initiative when speaking with her patients about unnecessary medical procedures. The Houston internist and chair of TMA's Council on Health Care Quality says that many patients request examinations that would not necessarily help their medical issue and could potentially cause harm. 

With reinforcement from Choosing Wisely, Dr. Ehrlich is able to steer patients in the right direction. 

The Choosing Wisely campaign is used to promote healthy dialogue between physicians and their patients. Begun in 2012, this physician-led movement attempts to eliminate unnecessary tests and procedures predicated on evidence-based recommendations. These recommendations come from leading medical specialty societies that have identified the five most salient issues patients could discuss with their physicians. TMA is working with the ABIM Foundation and the Robert Wood Johnson Foundation to make physicians and the public more aware of the lists and encourage their use.

Dr. Ehrlich is using the Choosing Wisely recommendations from the American College of Physicians (ACP) when consulting with her patients. The first two recommendations from the list are the most important for her practice, she says. 

Don't obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. 

Don't obtain imaging studies in patients with non-specific low back pain.

"We have a lot of false-positives from stress EKG tests," Dr. Ehrlich said, "about 15 percent from males, and an upward of 30 percent from females." Dr. Ehrlich states that this test is not necessarily helpful for low-risk and asymptomatic individuals. 

The use of imaging for non-specific back pain is another important Choosing Wisely recommendation Dr. Ehrlich quite often confronts in her practice.

"We use an MRI from the back or neck if we think something is encroaching on the spinal column that would then require surgical intervention," she said. "If we are going to do anti-inflammatory medication and physical therapy, then an MRI would not change our management for that.

"Choosing Wisely is a very easy thing that I can show the patient that these tests are not necessary and would not change my management."

When asked why she would recommend it to other physicians, Dr. Ehrlich said she believes "the initiative is important in getting physicians to think about how they can start talking to patients." In the future, Dr. Ehrlich will continue to use the Choosing Wisely recommendations when discussing tests and procedures with her patients. 

Dr. Ehrlich explains that the Choosing Wisely recommendations reinforce what is in the best interest of the patient's health. "It's not because we don't want to give a patients an x-ray," Dr. Ehrlich said. "It's that an x-ray gives the patients radiation and doesn't change our management."

The American College of Physicians offers three other Choosing Wisely recommendations: 

In the evaluation of simple syncope and a normal neurological examination, don't obtain brain imaging studies (CT or MRI).

In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don't obtain imaging studies as the initial diagnostic test.

Don't obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

For more information about the initiative, visit TMA's Choosing Wisely page at

Texas Medicine, Mar. 2015

Last Updated On

May 13, 2016

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