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Research Letter
Less Is More
April 2015

Development of Choosing Wisely Recommendations for an Inpatient Internal Medicine Service

Author Affiliations
  • 1Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
  • 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
JAMA Intern Med. 2015;175(4):642-644. doi:10.1001/jamainternmed.2014.8119

As part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign,1 more than 60 specialty societies have published lists of 5 tests, procedures, or treatments that physicians and patients should question. Recognizing the opportunity for the provision of higher-value care in our own setting, we developed a Choosing Wisely list for the inpatient General Internal Medicine service at Mount Sinai Hospital (MSH), one of the affiliated teaching hospitals at University of Toronto.


All attending physicians who care for patients on the General Internal Medicine service at MSH were invited to recommend 2 commonly ordered tests or procedures for inclusion on our Choosing Wisely list and to participate in an iterative voting process to identify the 5 items that are least likely to be of net benefit to patients. Once solicitation of initial suggestions was complete, the participants were asked to select exactly 5 items for the final Choosing Wisely list via an anonymous online survey. The physicians were not asked to rank their selections. The results of each round of voting were distributed to the participants, and the least popular items were eliminated from consideration before subsequent rounds. The selection process was repeated until 5 items had more votes than the remainder of the suggestions, comprising our final Choosing Wisely list. Institutional review board approval was neither obtained nor waived because no patient information was used.


Fifteen attending physicians agreed to participate, and a total of 31 initial suggestions were received. The initial list and results of voting are published in Table 1. Fourteen (45%) items received 2 or fewer votes (<15% of participants) in the first round of voting and were eliminated. Consensus regarding the top 5 items (those with the most votes) for the final list was achieved in the second round of voting. The top 5 recommendations were each endorsed by a minimum of 40% of the participants, with the top recommendation being endorsed by more than 50% of participants. The final Choosing Wisely list for the inpatient internal medicine service at MSH is shown in Table 2.


To our knowledge, this is the first instance of an individual hospital division developing its own Choosing Wisely list. While the selected items may not be generalizable beyond our scope of practice, the exercise of identifying areas of improvement can be applied in any setting. A potential weakness of our study is the reliance on expert opinion, although substantial evidence supports each of the items we generated. A further possible weakness is the potential for random variation in voting patterns to determine the final outcome owing to our small sample size. However, the general consensus among participants was that the number of high-quality suggestions on the initial list was in excess of 5, making it unlikely that our final list is invalid. Finally, in a small department like ours, we were concerned about the potential for a small number of individuals having an undue influence over the final outcome, which we mitigated through the anonymous online voting process.

Our list is unique to the inpatient internal medicine service, and perhaps to our local environment at MSH. As the complexity of medicine increases, physicians will face difficult choices regarding how best to investigate and treat patients’ conditions. We must also be mindful of the value our care provides in a resource-constrained world. Initiatives such as this are one way to address these problems in the future.

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Article Information

Corresponding Author: Allan S. Detsky, MD, PhD, FRCPC, Mount Sinai Hospital, 600 University Ave, Room 429, Toronto, ON M5G 1X5, Canada (adetsky@mtsinai.on.ca).

Published Online: February 23, 2015. doi:10.1001/jamainternmed.2014.8119.

Author Contributions: Drs Gupta and Detsky had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gupta.

Administrative, technical, or material support: Detsky.

Conflict of Interest Disclosures: None reported.

American Board of Internal Medicine Foundation.  Choosing wisely: an initiative of the ABIM foundation.http://www.choosingwisely.org. Accessed January 6, 2014.