Choosing Wisely - The Annals of Thoracic Surgery

SPECIAL REPORT

Choosing Wisely: Cardiothoracic Surgeons Partnering With Patients to Make Good Health Care Decisions Douglas E. Wood, MD, John D. Mitchell, MD, DeLaine S. Schmitz, RN, MSHL, Sean C. Grondin, MD, MPH, John S. Ikonomidis, MD, PhD, Faisal G. Bakaeen, MD, Robert E. Merritt, MD, Dan M. Meyer, MD, Susan D. Moffatt-Bruce, MD, PhD, T. Brett Reece, MD, and Michael A. Smith, MD University of Washington, Seattle, Washington (DEW); University of Colorado Denver School of Medicine, Aurora, Colorado (JDM, TBR); The Society of Thoracic Surgeons, Chicago, Illinois (DSS); Foothills Medical Centre, Calgary, Alberta, Canada (SCG); Medical University of South Carolina, Charleston, South Carolina (JSI); Baylor College of Medicine, Houston, Texas (FGB); Falk Cardiovascular Research Center, Stanford, California (REM); University of Texas Southwestern, Dallas, Texas (DMM); Ohio State Medical Center, Columbus, Ohio (SDM); St. Joseph’s Hospital and Medical Center, Phoenix, Arizona (MAS)

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hoosing Wisely is an initiative focused on helping physicians to be better stewards of finite health care resources and encouraging physicians and patients to discuss appropriate medical decision making. The principles focus on the imperative of helping physicians and other stakeholders make wise, evidence-based decisions that simultaneously promote high-quality care, and also assure sustainability of the health care system. Patients are engaged in partnership with Consumer Reports, who have promoted Choosing Wisely as “educating consumers about appropriate care.” Variability in health care and a quest for safety and value have highlighted the perils associated with overuse or misuse of procedures and tests, and an appreciation of the unintended consequences of patient harm and increased costs. The initiative originated from a physician charter on medical professionalism published in 2002 and subsequently endorsed by more than 130 medical professional societies that articulates commitment to improving access to high-quality health care, and advocates for a just and cost-effective management of finite health care resources [1]. The Promoting Good Stewardship in Medicine project piloted by the National Physicians Alliance was funded in 2009 by the American Board of Internal Medicine (ABIM) Foundation’s “Putting the Charter into Practice” grant. The initial project resulted in three lists of five specific steps that physicians in internal medicine, family medicine, and pediatrics could utilize in their practice to encourage effective use of health care resources [2]. This original campaign evolved into the multiple-year Choosing Wisely initiative in which the ABIM Foundation reached out to specialty societies to identify a list of five tests or procedures that may be overused or misused. Criteria for developing a Choosing Wisely list were as follows: (1) limited to items that fall within the purview of the specialty; (2) supported by evidence; (3) thoroughly Address correspondence to Dr Wood, Division of Cardiothoracic Surgery, University of Washington, Box 356310, 1959 NE Pacific, AA-115, Seattle, WA 98195-6310; e-mail: [email protected].

© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc

documented and publicly available upon request; (4) frequently ordered/costly; (5) easy for a lay person to understand; and (6) measurable/actionable. The first release of the Choosing Wisely initiative took place in April 2012 when nine specialty society lists were released. Recommendations were disseminated to physicians and consumers through a collaborative effort between the ABIM Foundation and Consumer Reports. There was a uniformly favorable public response, with the physician groups praised for their professionalism and proactive efforts to improve utilization of health care resources while empowering a dialogue between patients and physicians regarding appropriateness of many commonly performed tests and procedures. Sixteen additional specialty societies, including The Society of Thoracic Surgeons (STS), are participating in the February 2013 phase II release, and several other specialty groups are slated for a release later in 2013. Participation in Choosing Wisely is a proactive and responsible initiative to improve the physician-patient dialogue, enhance patient safety, and to be accountable for the use of health care resources.

Creation of STS Choosing Wisely List In May 2012, STS Executive Committee agreed to participate in phase II of the Choosing Wisely initiative and appointed Douglas E. Wood, MD, as first vice president, to lead the project. The list selection process involved input from several workforces, including the Workforce on Adult Cardiac and Vascular Surgery, Workforce on General Thoracic Surgery, and Workforce on EvidenceBased Surgery.

Selection of Draft Recommendation Initial conference calls with the chairs of the Workforce on Adult Cardiac and Vascular Surgery, Workforce on General Thoracic Surgery, and Workforce on EvidenceBased Surgery provided each chair with an overview of Ann Thorac Surg 2013;95:1130 –5 • 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.01.008

Ann Thorac Surg 2013;95:1130 –5

SPECIAL REPORT WOOD ET AL CHOOSING WISELY FOR GOOD HEALTH CARE DECISIONS

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Table 1. Possible Misused/Overused Cardiothoracic Tests/Procedures: Seventeen Initial Candidates for Consideration Provided by STS Workforces Workforce on Adult Cardiac and Vascular Surgery

2. No need for pulmonary function tests if no respiratory symptoms, able to climb 3 flights of stairs 3. No need for unstable angina unless symptoms

4. No need for daily laboratory draws in hospital unless purpose driven 5. No need for chest roentgenogram unless purpose driven 6. No need for discharge echocardiography on valve patients 7. No need for discharge computed tomography scan on aortic surgery patients

1. Patients with suspected or biopsy proven stage I non-small cell lung cancer who are asymptomatic do not require brain imaging before definitive care 2. Patients who have no cardiac history do not require preoperative stress testing before noncardiac thoracic surgery 3. Chest computed tomography scans for screening and follow-up of solitary pulmonary nodules should be performed at intervals as determined by the Fleisher guidelines 4. Comprehensive metabolic panels are not indicated for routine preoperative screening in otherwise healthy patients preparing for noncardiac thoracic surgery 5. Patients with localized esophageal cancer who are asymptomatic do not require bone scan imaging before definitive care 6. A statement about the frequency of postoperative lung cancer follow-up, namely, every 3 to 4 months or every 6 months? 7. Echocardiography to estimate pulmonary hypertension in lung volume reduction surgery and other high-risk lung surgeries is inaccurate and of little practical use 8. Pulmonary function testing in low-risk patients going for wedge (ie, solitary lung metastasis) is unnecessary 9. Routine frozen section of bronchial margins for peripheral lung cancers is unnecessary 10. For routine pulmonary resections for cancer, antibiotic prophylaxis does not need to continue until all chest tubes are removed

the Choosing Wisely initiative, the criteria for list selection provided by the ABIM Foundation, and the project time line. The Workforce on Adult Cardiac and Vascular Surgery and Workforce on General Thoracic Surgery were assigned to work with their respective workforce to identify five to 10 overused or misused procedures or tests in the areas of adult cardiac and general thoracic surgery. Seventeen candidates for consideration were provided by the two workforces (Table 1). Based on the criteria outlined by the ABIM Foundation, the workforce chairs and Dr Wood narrowed the list from 17 recommendations to eight, which were subsequently approved by STS leadership to undergo further vetting by a membership survey, as well as evaluation of the evidence by the Workforce on Evidence-Based Surgery (Table 2).

Vetting the Draft Recommendations Member Survey The US STS membership was informed of the Choosing Wisely initiative on July 10, 2012, by STS Weekly, an e-communication designed to alert members to important deadlines, announcements, and other timely information. The announcement included a link to an online survey inviting participants to review the Choosing Wisely criteria provided by the ABIM Foundation and indicate their level of agreement with the eight draft recommendations. The Zoomerang survey utilized a fivepoint scale ranging from strongly agree to strongly dis-

agree. Members who did not agree with a draft recommendation were encouraged to provide a rationale and a peer-reviewed reference to support their position. Seventy-five percent to 90% of respondents either agreed or strongly agreed to six of the eight draft recommendaTable 2. Eight Recommendations of Cardiothoracic Tests/ Procedures Approved to Undergo Further Vetting by STS Membership Survey and Evaluation by STS Workforce on Evidence-Based Surgery 1. Patients who have no cardiac history do not require preoperative stress testing before noncardiac thoracic surgery 2. Before cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms 3. Before cardiac surgery, there is no need for a routine carotid workup in the absence of symptoms 4. Patients with suspected or biopsy proven stage I NSCLC do not require brain imaging before definitive care in the absence of neurologic symptoms 5. Prophylactic antibiotics should not be continued beyond 24 hours postoperatively after thoracic surgery, or beyond 48 hours after cardiac surgery 6. Chest computed tomography scans for follow-up of solitary pulmonary nodules should not be performed more frequently than intervals recommended by Fleisher guidelines. 7. A predischarge echocardiogram is not needed after cardiac valve replacement surgery 8. It is not necessary to obtain daily chest roentgenograms and blood laboratory tests after cardiothoracic surgery in the absence of clinical indications

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1. No need for carotid ultrasonography unless left main disease, symptoms or carotid bruits

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tions. The other two draft recommendations received less member support, with 50% and 54% of respondents either agreeing or strongly agreeing.

Evidence Review Each of the eight recommendations was assigned to a member of the Workforce on Evidence-Based Surgery with instructions to conduct a systematic search of the literature using Ovid MEDLINE, CINAHL, and the Cochrane Library with the help of a university librarian. Based on the literature search findings, the Workforce members were asked to draft evidentiary statements utilizing the template provided by the ABIM. Six of the eight draft recommendations were considered to be supported by the scientific evidence, whereas two recommendations were not.

Selection of the Final Five Recommendations On August 15, 2012, Dr Wood presented the evidentiary statements for each of the eight recommendations to STS Executive Committee by conference call. The Executive Committee discussed the list in detail and rejected the two recommendations that lacked supporting evidence. An additional recommendation was rejected because it was already a PQRS performance measure; therefore, it was less likely to have an impact than one of the other recommendations. The Executive Committee approved the remaining five recommendations, thereby finalizing the Society’s Choosing Wisely list.

(1) Patients Who Have No Cardiac History and Good Functional Status Do Not Require Preoperative Stress Testing Before Noncardiac Thoracic Surgery ●

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Functional status has been shown to be reliable for prediction of perioperative and long-term cardiac events. In highly functional asymptomatic patients, management is rarely changed by preoperative stress testing. It is, therefore, appropriate to proceed with the planned surgery without it. Preoperative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications such as history of ischemic heart disease, heart failure, cerebrovascular disease, diabetes mellitus, and chronic renal insufficiency, and patients needing pneumonectomy.

Unnecessary stress testing in patients with low risk for cardiac complications can be harmful because it increases the cost of care and delays treatment without altering surgical or perioperative management in a meaningful way. Furthermore, low-risk patients who undergo preoperative stress testing are more likely to receive beta-blockers, which can have unnecessary and deleterious effects in low-risk patients. Cardiac complications are indeed significant contributors to morbidity and mortality after noncardiac thoracic


surgery, and it is important to identify patients preoperatively who are at risk for these complications. The most valuable tools in this endeavor include a thorough history, physical examination, and resting electrocardiogram. Cardiac stress testing can be an important adjunct in this evaluation, but it should be used only when clinically indicated.

Sources 1. Fleisher LA, Beckman JA, Brown KA, et al. ACC/ AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for non-cardiac surgery). Circulation 2007;116:e418-99. 2. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-Cardiac Surgery of the European Society of Cardiology. Eur Heart J 2009;30:2769-812. 3. Brunelli A, Varela G, MD, Salati M, et al. Recalibration of the revised cardiac risk index in lung resection candidates. Ann Thorac Surg 2010;90:199-203. 4. Wijeysundera DN, Beattie WS, Elliot RF, et al. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study. BMJ 2010;340:b5526.

(2) Do Not Initiate Routine Evaluation of Carotid Artery Disease Before Cardiac Surgery in the Absence of Symptoms or Other High-Risk Criteria ●

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Studies show that the presence of asymptomatic carotid disease in patients undergoing cardiac surgery does not import the clinical significance to justify preoperative screening in more than the subgroup of “high-risk” patients. High-risk patients include those with history of cerebrovascular accident or transient ischemic attack, left main coronary disease, peripheral vascular disease, hypertension, smoking, diabetes mellitus, or age more than 65 years. Data suggest the incidence of perioperative stroke to be related more to the atherosclerotic burden the patient may have rather than to the degree of carotid artery stenosis. The presence of increased severity of carotid artery stenosis or the presence of a carotid bruit does not equate to an increased risk of stroke after cardiac surgery. Intraoperative techniques of optimizing hemodynamics and minimizing aortic manipulation in at-risk patients may have more effect on decreas-

ing the risk of stroke after cardiac surgery than the use of preoperative carotid artery screening for the majority of patients. The ACC/AHA 2011 guidelines for coronary artery bypass graft surgery recommended carotid artery screening to reduce neurologic complications in a subset of higher risk patients. In addition, a recent consensus report from the United Kingdom questioned whether neurologic sequellae developing in cardiac surgery patients with asymptomatic carotid disease are due to the carotid artery disease or rather act as a surrogate for an increased stroke risk from atherosclerotic issues with the aorta. Although the consensus panel acknowledged the clinical importance of bilateral carotid disease (ⱖ70% stenosis) in the setting of cardiac surgery, they found the concept of routine screening to lack supporting data regarding cost effectiveness. Instead, they recommended targeting “high-risk” patients for preoperative carotid artery evaluation. In a series of more than 45,000 patients undergoing coronary artery bypass graft surgery at the Cleveland Clinic published in 2011, a 1.6% incidence of stroke was observed, with the majority of strokes (58%) occurring postoperatively. Risk factors for stroke identified included older age and variables suggesting a significant atherosclerotic burden. The larger proportion of postoperative strokes point to issues other than carotid artery stenosis as a causative factor for stroke. A recent meta-analysis examining the issue of stroke after cardiac surgery in the patients with asymptomatic carotid disease found that patients with unilateral disease did not have increasing risk of stroke with increasing severity of the stenosis. Finally, even the presence of a carotid bruit correlates poorly with the degree of carotid stenosis. The Northern Manhattan Stroke Study concluded that carotid duplex studies should be considered in high-risk asymptomatic patients, irrespective of findings on auscultation [6].

Sources 1. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/ AHA guideline for coronary artery bypass graft surgery. Circulation 2011;124:e652-735. 2. Stansby G, Macdonald S, Allison R, et al. Asymptomatic carotid disease and cardiac surgery consensus. Angiology 2011;62:457-60. 3. Tarakji KG, Sabik JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA 2011;305:381-90. 4. Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41:607-24. 5. Cournot M, Boccalon H, Cambou JP, et al. Accuracy of the screening physical examination to identify subclinical atherosclerosis and peripheral arterial disease in asymptomatic subjects. J Vasc Surg 2007; 46:1215-21.


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6. Ratchford EV, Jin Z, Di Tullio MR. Carotid bruit for detection of hemodynamically significant carotid stenosis: the Northern Manhattan Study. Neurol Res 2009;31:748-52.

(3) Do Not Perform a Routine Predischarge Echocardiogram After Cardiac Valve Replacement Surgery ●

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Predischarge cardiac echocardiography is useful after cardiac valve repair. It provides information regarding the integrity of the repair and allows the opportunity for early identification of problems that may need to be addressed surgically during the index hospitalization. Unlike valve repair, there is lack of evidence that supports the routine use of cardiac echocardiography predischarge after cardiac valve replacement. Scenarios that would justify the use of predischarge cardiac echocardiography include inability to perform intraoperative transesophageal echocardiography, clinical signs and symptoms worrisome for valvular malfunction or infection, or a large pericardial effusion.

Although there are no studies specifically addressing the timing of the initial postoperative evaluation of a cardiac prosthetic valve for establishment of baseline readings, existing guidelines recommend a postoperative transthoracic echocardiographic study at the first visit, 2 to 4 weeks after hospital discharge. At that time, surgical incisions are better healed, ventricular function has had the opportunity to recover or improve, and anemia with its attendant hemodynamic state has abated.

Sources 1. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr 2009;22:975-1014. 2. Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Circulation 2006;114:e84-231. 3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Circulation 2008;118:e523-661.

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4. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/ SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67.

(4) Patients With Suspected or Biopsy Proven Stage I NSCLC Do Not Require Brain Imaging Before Definitive Care in the Absence of Neurologic Symptoms

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The brain is a frequent site of extrathoracic metastasis associated with non-small cell lung cancer (NSCLC). Some clinicians perform routine screening by brain magnetic resonance imaging (MRI) or computed tomography (CT) scans to rule out occult brain metastasis in asymptomatic patients before surgical resection of early stage lung cancer. The purported benefits of early detection of intracranial brain metastases include avoidance of a noncurative pulmonary resection and early treatment of solitary brain metastasis. This practice of routine screening for occult brain metastases has not been evaluated by a randomized clinical trial and may not be cost effective. In most studies, the diagnostic yield of CT scanning or MRI of the brain in NSCLC patients (of varying stages) with a negative neurologic examination is 0% to 10%. Pooled data from retrospective studies that included a comprehensive clinical evaluation demonstrated that only 3% of patients who have a negative neurologic evaluation present with intracranial metastasis. At least one study, limited to stage I patients, reported a prevalence of 1.3%. The current published literature on routine brain imaging with either MRI or CT scan is conflicting; however, most reports do not support routine screening for occult brain metastases. The joint statement of the American Thoracic Society and the European Respiratory Society published in 1997 did not advocate preoperative imaging of the brain in patients with NSCLC who present without neurologic symptoms. Toloza and colleagues determined that the estimated negative predictive value of clinical neurologic examination for the evaluation of brain metastases was 94%; therefore, the investigators concluded that routine imaging in asymptomatic NSCLC patients is not warranted. In addition, the current National Comprehensive Cancer Network (NCCN) NSCLC guidelines do not recommend preoperative brain imaging for asymptomatic patients with Stage IA NSCLC.


Sources 1. Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer. ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132(Suppl):178-201. 2. Tanaka K, Kubota K, Kodama T, Nagai K, Nishiwaki Y. Extrathoracic staging is not necessary for non-small-cell lung cancer with clinical stage T1-2 N0. Ann Thorac Surg 1999;68:1039-42. 3. American Thoracic Society and European Respiratory Society Consensus Report. Pretreatment evaluation of non-small cell lung cancer. Am J Respir Crit Care Med 1997;156:320-32. 4. Toloza EM, Harpole L, McCory DC. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Chest 2003;123(Suppl):137-46. 5. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: non-small cell lung cancer. Version 3.2011.Available at: www. nccn.org/professionals/physician_gls/pdf/nscl.pdf. 6. Colice GL, Birkmeyer JD, Black WC, Littenberg B, Silvestri G. Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of metastases. Chest 1995;108:1264-71.

(5) Before Cardiac Surgery There Is No Need for Pulmonary Function Testing in the Absence of Respiratory Symptoms Pulmonary function tests can be helpful in determining risk in cardiac surgery, but patients who have no pulmonary disease are unlikely to benefit, and testing may not be justified. Symptoms attributed to cardiac disease that are respiratory should be better characterized with pulmonary function tests, especially in patients prone to pulmonary disease such as smokers and patients with strong family or occupational history. Risk models for cardiac surgery developed from review of STS National Adult Cardiac Database incorporate a variable for chronic lung disease. The degree of lung impairment (denoted as none, mild, moderate, or severe) is a composite based on the patient’s forced expiratory volume in 1 second (FEV1) impairment, use of pharmacologic aids to control respiratory symptoms, and pulmonary history. Only recently have actual FEV1 and diffusion capacity of lung for carbon monoxide data been collected in the database. “None” is the baseline for risk with chronic lung disease. In the absence of respiratory symptoms or suggestive medical history, pulmonary function testing is quite unlikely to change patient management or assist in risk assessment. Although some data are beginning to emerge about preoperative pulmonary rehabilitation before cardiac surgery for patients with even mild to moderate obstructive disease, that does not directly extrapolate to asymptomatic patients.

Sources 1. Shahian DM, O’Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models. Part 1— coronary artery bypass grafting surgery. Ann Thorac Surg 2009;88(Suppl):2-22. 2. O’Brien SM, Shahian DM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models. Part 2—isolated valve surgery. Ann Thorac Surg 2009;88(Suppl):23-42. 3. Ried M, Unger P, Puehler T, Haneya A, Schmid C, Diez C. Mild-to-moderate COPD as a risk factor for increased 30-day mortality in cardiac surgery. Thorac Cardiovasc Surg 2010;58:387-91. 4. Adabag AS, Wassif HS, Rice K, et al. Preoperative pulmonary function and mortality after cardiac surgery. Am Heart J 2010;159:691-7.

Conclusions STS has long been a leader in data-driven and patientcentered health care. That has been highlighted by clinical risk-adjusted databases, quality initiatives such as ProvenCare Lung Cancer, and a long history of development of rigorous evidence-based guidelines to inform clinical practice. Choosing Wisely allows STS to continue that leadership alongside like-minded specialty societies


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to empower the physician-patient dialogue and to avoid unnecessary procedures that may harm patients while driving up health care costs. Responsible use of health care resources is one of the key principles of professionalism that cardiothoracic surgeons and other physicians advocate and adhere to. Patients need to know when to say “whoa!” to doctors, and physicians need to be empowered to avoid tests or procedures that are not supported by evidence. If we have selected those procedures correctly, a common response should be “but that is what I do!” That is the point. The goal is to challenge common practice; practice that may be imbedded in tradition, routine, or defensive medicine, yet does not have good justification. The Choosing Wisely list is not meant to be rigid or constraining, but is meant to educate both surgeons and patients, and to empower the two together to make better decisions about their health care choices.

References 1. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243– 6. 2. The Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med 2011;171:1385–90.

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