“Whatever word or action you send to the Universe, You’ll receive it back. Choose wisely.”

- Anoir Ou-chad, The Alien -

The National Academy of Medicine of Korea just initiated the “Choosing Wisely Korea” initiative, and the Korean Society for Vascular Surgery (KSVS) was invited to participate in the campaign [1]. When I attended an early morning meeting in March 2022, I was surprised to learn that the program had been initiated two years previously, although this had not been widely known.

Five professional societies relating to internal medicine, radiology, laboratory medicine, urology and thoracic surgery had published 5 to 7 lists in their specialties. For unknown reasons, the Korean Surgical Society elected not to participate in the campaign. Now that the KSVS has been re-invited to participate in the 2nd phase of the campaign, the leadership of the KSVS has decided to participate. This editorial intends to explain the campaign and to urge the KSVS members to participate actively in it.

The “Choosing Widely” initiative was first led by the American Board of Internal Medicine (ABIM) Foundation with professional societies in 2012, aiming to reduce wasteful medical care [2]. Rational and cost-effective care is a key principle for modern healthcare professionals, especially with restricted healthcare resources. The Choosing Wisely initiative requests that leading physician specialty societies create a “Top 5” list of medical services that provide no overall benefit to patients in most situations. The Choosing Wisely initiative continues to help patients and doctors choose care that is supported by evidence and is truly necessary.

This initiative was attractive for me as many overtreatments are popular in Korea, due to the distorted medical insurance system governed by the National Insurance Policy and commercial personal health insurance plans. As I mentioned in a previous editorial [3], endovenous varicose vein surgery is a clear example of overtreatment in Korea and the USA. Hence, this kind of campaign to educate the public and doctors about unnecessary examinations or procedures is quite necessary.

Furthermore, the merit of this campaign has evolved to include issues of trust in healthcare and of how trust contributes to better health care outcomes, increased patient satisfaction, and greater physician well-being. The mission of Choosing Wisely is to promote conversations between clinicians and patients by helping patients choose care that is: 1) Supported by evidence; 2) not duplicative of other tests or procedures already received; 3) free from harm; and 4) truly necessary [2]. To help patients engage their health care provider in these conversations and to empower them to ask questions about what tests and procedures are right for them, patient-friendly materials were created based on the specialty societies’ lists of recommendations of tests and treatments that may be unnecessary. Now the campaign is widespread in the USA, Canada, Europe, Japan and Australia, in conjunction with OECD.

The Society for Vascular Surgery announced five things physicians and patients should question in the field of vascular surgery in 2015 [4]:

• Avoid routine venous ultrasound tests with asymptomatic telangiectasia.

• Avoid routine ultrasound and fistulogram evaluations of well-functioning dialysis accesses.

• Do not use IVC filters for the primary prevention of pulmonary emboli in the absence of either a contraindication to anticoagulation or recurrent venous thromboembolic events while on therapeutic anticoagulation.

• Do not use interventions (including surgical bypass, angiogram, angioplasty or stent) as a first line treatment for most patients with intermittent claudication.

• Avoid use of ultrasound for routine surveillance of carotid arteries in the asymptomatic healthy population.

It is not easy for Korean patients to ask doctors about the rationales for the exams they are recommended. However, the Choose Wisely campaign starts by asking doctors basic questions directly: 1) Is this exam or treatment really necessary? 2) What kind of risks does the treatment contain? 3) Is there any simple and safer alternative? 4) Is observation without any exam or therapy acceptable? 5) How much is the cost of care? These questions are not to be debated with doctors, but to enhance trust and rapport between patients and surgeons.

The National Academy of Medicine of Korea recommends that seven steps be followed to resolve the top five questions, in collaboration with the Institute for Evidence-Based Medicine: 1) Plan and organize a study group. 2) Draft a list after considering the pre-existing questions from guidelines and benchmarking Choosing Wisely in other countries. 3) Survey the responses of the specialty society members. 4) Collect evidence for the list. 5) Use the big data from the National Health Insurance Service. 6) Perform an external review and obtain secondary opinions; and 7) revise the draft and announce the final list of five unnecessary practices.

I think this is the good time for the members of the KSVS to understand the goals and merits of the Choose Wisely Korea, and to actively participate in the campaign. This will benefit, not only the patients, but also the vascular surgeons in the long term. Vascular surgeons are the main caregivers in many vascular diseases including abdominal aortic aneurysms, peripheral arterial diseases, deep vein thrombosis, varicose veins, vascular access for hemodialysis, and others. We are caregivers in concordance with evidence-based practice. This will ensure trust with patients and result in better outcomes, helping to win turf wars in the field of vascular surgery.

Seung-Kee Min has been the editor-in-chief of Vasc Specialist Int since 2019.