Considering Cocreation for the Choosing Wisely List

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In their August 2016 article, Lakhani et al1 created an innovative Choosing Wisely list to improve awareness and empowerment among medical students in reducing overuse. This project was expansive and engaged students from all 17 medical schools across Canada. As broad and inclusive as this undertaking was, the list was developed without input from the primary end user—the patient.
The American Board of Internal Medicine (ABIM) Foundation intended Choosing Wisely to promote conversations between clinicians and patients about unnecessary care. These lists were developed by clinician societies with messaging to patients facilitated by media outlets and Consumer Reports. These were successful in spreading the message, but the architects of Choosing Wisely have recently shifted focus from awareness to implementation, understanding that systems change, and not knowledge alone, is needed to improve outcomes.
Health care is a service that is cocreated between providers and patients.2 Far from a product developed from a manufacturer for a consumer, health care service is a complex system with great potential for patients to improve value at every stage, including design, production, delivery, and evaluation. Instead of involving patients after the Choosing Wisely list is finalized, we propose involving patients from its inception.
Two significant drivers of overuse perceived by clinicians include fear of litigation and patient demand.3 These barriers could be lowered if health care standards were developed in partnership with patients. Imagine a process in which brainstorming recommendations for the Choosing Wisely list included what matters most to patients, as told by the patients. Perhaps what matters to patients in reducing unnecessary care is discussion about cost, or potential harms of testing and treatment. A Delphi process could facilitate equal say among clinicians and patients in this collaborative process. Cocreation could revitalize Choosing Wisely list development and improve implementation in the years to come.
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