Accessibility Page Navigation
Style sheets must be enabled to view this page as it was intended.
The Royal College of Psychiatrists Improving the lives of people with mental illness

Choosing wisely

Choose Wisely


If we are to counteract cultural pressures in health care that give rise to overuse of tests and interventions, what factors should we base our decisions on?

Clinical decisions are often complex. There are many factors to take into account and many pressures within the health care context that pull us in different ways. Worryingly, there is increasing evidence of a general overuse of tests, interventions and procedures. In the United States as much as 20% of money spent in health care brings no benefit to patients. I spent the last week in Amsterdam at a “Choosing Wisely’ roundtable event which discussed how best to engage doctors with this important issue.


The 'Choosing Wisely’ initiative has had a big splash in the US and Canada and is inspiring clinicians to have robust discussions with patients about what interventions and tests are most helpful. The premise of ‘Choosing Wisely’ is that overuse of tests and interventions is due to many factors but can be overcome by having new types of conversations with patients about the pros and cons of each option.


How can we ensure that we deliver the right intervention at the right time to the right person without overusing increasingly precious financial and environmental resource? The answer is of course multifactorial but I think that a good understanding of the cultural factors that influence doctors’ decision making would certainly be helpful. In addition to this, doctors should be aware of the clinical factors they should base their decisions on.


Cultural pressures that influence clinical decisions include defensive practices, clinical habits (“it’s the way we do things around here”), marketing forces from med-tech and big pharma, as well as looking good in front of seniors on a ward round. Commissioning structures that are based on activity rather than results also affect our clinical practices. If we are to fly in the face of these insidious pressures and ensure that we remain focused on providing interventions with the highest value for patients, what factors should we base our decisions on?


I believe a doctor needs to have a balanced view on four factors in order to make sustainable and ‘wise’ clinical decisions:

1.      Patient benefit

2.      Patient harm

3.      Patient preference

4.      Resource use


Currently, perhaps there is too much focus on the benefit that any intervention might achieve to the neglect of the other three factors. This unbalanced view is potentially leading to an overuse of clinical resource. Doctors have a difficult job weighing up many factors in each clinical decision they make, greater clarity about these factors would enable doctors to make more responsible and sustainable decisions.




Subscribe to this post's comments using RSS


Add a Comment
  • Security Verification:
    Type the numbers you see in the picture below.
    Type the numbers you see in this picture.
Login - Members Area

If you don't have an account please Click here to Register

Make a Donation

Fellowship in Sustainability blog




Our College is working with the Centre for Sustainable Healthcare to create a network of those interested in promoting sustainability in mental health services.


Sustainable healthcare is about ensuring we provide good quality health care today without compromising the ability of future generations to provide the same quality of health care. As clinicians, we need to be more aware of the impacts that mental health services are having on society and the wider world. Mental health professionals could lead the way in promoting a health service that is good for the environment and is also good for patients and the communities they live in. Find out more...

  Dr Daniel Maughan  

Daniel Maughan is the RCPsych Research Fellow in Sustainability. This is a two-year fellowship to improve the sustainability of mental health services. Daniel will work with the Centre for Sustainable Healthcare, the RCPsych and the University of Warwick to create a network of sustainability representatives in mental health services across England.  JOIN THIS NETWORK

This fellowship’s aims include researching innovations and new models of care and stimulating the adoption of sustainable practices in mental health Trusts around the country. 

Daniel is pursuing this fellowship as an OOPE from his psychiatric training. He has recently completed ST5 in General Adult Psychiatry in Oxford Deanery and the NHS clinical leadership fellowship program. He is also a researcher with the Social Psychiatry Group at Oxford University Department of Psychiatry. 

If you would like to contribute to our Blog Zone series, please email an outline of your blog to: