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The emergency department (ED) is a unique practice environment that functions simultaneously as a place for high-acuity care of life-threatening illness and injury and also as a safety net for patients with chronic untreated disease. Patient presentations reflect not only pathophysiological derangements in individuals but also the consequences of social dysfunction as well as of healthcare itself, the latter related to the contrasting harms of poor access (in many cases) and excessive intervention (in many others). As changes in the larger healthcare system lead to more frequent use of the ED, clinicians have less time to spend with increasingly sick patients, resulting in more testing and less listening,1 as well as burnout among providers and medical harm and financial cost for patients.1–3
In attempting to address overuse in medicine, the Choosing Wisely campaign asked medical specialty societies to develop lists of diagnostic and therapeutic interventions that are being undertaken too frequently, leading to waste and harm.4 While different individuals and groups might not agree on every item identified, the ‘top 5’ lists that emerged from this process reflected in part an attempt to avoid controversy and left some important items—indeed some critical ‘elephants in the room’—unmentioned. While specialty societies do undertake advocacy work to address the health needs of the public, they also have a fundamental duty to advocate for and protect the interests of their specialty. Furthermore, healthcare dollars that are ‘wasted’ are of course not actually thrown away but rather end up in someone’s pocket; thus, there is clearly a conflict of interest when specialty societies address the overuse of extremely lucrative medical procedures that provide substantial income to their members.
The Right Care Alliance (RCA) is a US-based collaborative effort of healthcare practitioners and patients to address systemic issues of both overuse and underuse …
Contributors EW chaired the Emergency Medicine Council and moderated the development of the top 10 list. All authors participated in each step of the Modified Delphi process and contributed to the writing of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.