Choosing Wisely Canada (CWC) promotes activities to reduce utilization of unnecessary tests, treatments and procedures. Physicians, by nature of their autonomy and licensure, are uniquely positioned to drive healthcare utilization – whether utilization is deemed appropriate or not. CWC reliance on a strategy based on the uptake of recommended practices could be improved. We suggest that CWC focus on three objectives: enhancement of physician reimbursement models, alignment of their activities with a broader health system transformation agenda and the development of approaches to ensure physician accountability for cost and quality. These efforts may have been considered beyond the scope of CWC’s early work, but to move from a standard setting to real change, these difficult issues need to be addressed. CWC is in a very good position to advocate for these changes.