Appropriateness and surroundings: "Doing more does not mean doing better". Choosing wisely, an unfulfilled commitment?

The attention of the medical community to the appropriateness of diagnostic and therapeutic procedures has increased in recent years, recognizing the need for a careful use of resources and for avoiding unnecessary and sometimes harmful medical tests, procedures and therapies. Not only healthcare providers, but also public, patients and politicians, should know the consequences of inappropriate decisions and behaviors. Indeed, inappropriateness has clinical (risks), economic (waste of resources), but also ethical implications (i.e. the use of unnecessary tests and treatments in a system characterized by limited resources). Inappropriateness is a complex entity and it may vary widely: in fact, it may be influenced by different clinical settings, techniques used, but also by data collection methods, size of the population considered, and the professional background of the physicians requesting a specific test or procedure. Various initiatives have been proposed with the aim at reducing the use of unnecessary tests and procedures but imposed rules appear to be of dubious effectiveness. On the contrary, the medical community needs more in-depth knowledge of the problem and an active commitment for reducing the waste of resources, especially because unnecessary or sometimes harmful interventions subtract resources where they are useful or necessary. Recently, the "Choosing Wisely" campaign, which has involved 18 countries and more than 70 scientific societies, has been one of the most well-known initiatives, launched in Italy by the "Slow Medicine" movement. The purpose is to disseminate the recommendations of scientific societies with the aim to promote processes of care based on appropriateness, but within a relation of dialogue and decision sharing with the patient and public. The Choosing Wisely campaign is certainly important and innovative. However, there are open and unsolved issues such as the lack of rigorous and systematic methods for the evaluation of the results of the proposed initiatives and the need for more widespread interventions both at the medical and community level.