Over the last several years, there has been a plethora of discussion swirling around the appropriate use criteria (AUC); some of it reasoned but most, simply vitriolic. I have led projects attempting to use the AUC to extract data from electronic health records for quality improvement purposes, been witness to efforts to use the AUC in place of radiology benefits managers, and participated in numerous conversations related to the terms used to describe the categories and even the techniques employed to organize the classification for each scenario discussed.

I have learned a tremendous amount… but mostly I’ve learned that we really don’t know squat about what we are doing!

1. Medically, we don’t really know the correct treatment most of the time.  Although it might seem obvious to us in reflection, it is certainly not clear to the public that the great majority of what we do is rooted in best guess, we think it will work, expert consensus type evidence, not in “proven fact.”  More significantly, we have a history of being wrong, occasionally famously.  Examples such as “bypass surgery will prevent heart attack”, “antibiotics make a difference in otitis media”, and “frequent stress testing helps predict outcome” dot our historical landscape.  There are numerous others.  They all have in common the fact that we thought we knew what we were doing when we didn’t.
2. We do a very poor job of keeping ourselves up to date as to the changes in the current practice of medicine.  The reasons for this appear to be multiple; mostly we simply do not have time. We seem to spend far more time as a profession publishing cutting edge research than publishing practical consensus documents about what physicians should do in the care of their patients.
3. We resist change that has a negative impact on our belief system.  Let’s face it, it is human nature to protest being told “you’re doing it wrong” (but I would point out we do not mind being told “to do more”).  The recent discussion regarding angioplasty is an excellent example of that.  No interventional cardiologist wants to be told they are doing too many angioplasties or that they are unnecessary, however virtually every interventional cardiologist would like to be told “you can do twice as many as you are doing now and it is medically justified.”
4. We have a vested interest in enhancing our incomes.  Everybody does.  In the environment of a reduced physician fee schedule it is a difficult sell to convince a practicing physician to reduce their utilization (which they universally feel is appropriate) in the absence of good information.

So what shall we do, as individuals and as an organization?

1. We should encourage appropriate, evidence based care in as many situations as we can.  It is incumbent that organizations such as the ACC lead in developing those documents and standards on a timely basis and in a fashion that is easily available to all.  This might also mean that we admit we are not sure as to what the best strategy is in many circumstances. Transparency demands that admission of truth.
2. We should encourage a conservative approach in those areas that we do not know the correct answer. The concept of “less is more” certainly applies here.
3. We should, individually and as an organization, diligently work to continuously educate ourselves not only by maintaining relationship with  the current literature but also by striving to understand those far more basic principles that are often left behind.  The Million Hearts initiative is an excellent example of the fact that we need to provide the most fundamental level of education to our patients.  This means that we must embrace those fundamental tenets of care, basic though they may be, and strive to achieve them.

Finally we must be receptive and embrace change, even if it is uncomfortable for us personally, in order to provide that which is the best for our patients. Self-sacrifice is difficult, admitting you do not know is uncomfortable and recognizing that change occurs, inevitable.

In doing so, we strive to do what is best for our patients and our country.

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