What Matters to You? Day - June 6, 2017

"What Matters to You?" Day is June 6, 2017! Ask What Matters. Listen to What Matters. Do What Matters.

 

Medicine is undergoing a huge transformation, shifting away from the historic model of paternalistic, top-down, doctor-driven health care. We started towards patient-driven, consumer medicine, and thankfully are starting to settle at a beautiful middle-ground, which is patient-centred care, using interdisciplinary clinician expertise, and a process of shared decision making around a patient's needs and priorities.

That is a lot of words, when really what it boils down to is this: shifting the emphasis towards caring for people rather than 'doing medicine.'

Or in even simpler terms, we should be asking "What matters to you?" and shaping the care we give to help people find the best fit for their goals. 

This is a new initiative in British Columbia, organized by the BC Patient Safety Quality Council (BCPSQC), to promote meaningful conversations around health care between patients and providers. "What Matters to You?" Day is based on a now global campaign that started in Norway in 2014.

We already incorporate this into our work in the Palliative Care and 'ED2HOME' services at my hospital, but I am keen to help spread the word for this very important idea so that all patients have a chance to answer the question.

From the BCPSQC:

Why does it matter?
Because we believe great care begins with a question. Providing patient-centred care is important because it results in better outcomes for patients and greater satisfaction with care. “What Matters to You?” Day supports this by putting the patient voice at the centre of care, by focusing on what matters to them.

When a health care provider starts a conversation by asking what really matters to the person they are caring for, it helps them to build trust, develop empathy, and understand their patients. Ultimately, it improves the quality of care they provide.

There are lots of ways you can support "What Matters to You?" Day

  • Join us & declare your intention to have a conversation about what matters, whether you're a care provider, patient, family member, or health care provider
  • Download our Getting Started Kit & learn more about the campaign
  • Order free resources to promote "What Matters to You?" Day. We've got posters, pocket cards, stickers, and more resources designed for patients and providers. We'll mail them anywhere in BC! 
  • Spread the word online using our simple, prepared messages and digital resources!
  • Get ready for conversations about what matters with our skill-building tools
  • Watch and share the campaign video, above

Celebrate The Virtual Launch!
We'll be sharing messages about "What Matters to You?" Day across digital channels, so join the conversation on Twitter, Instagram, or Facebook by using the hashtag #WMTY17! You can even add a #WMTY17 Twibbon to your profile photo to spread the word with every message you share!

Learn more: What Matters to You Day

Source: https://bcpsqc.ca/what-matters-to-you-day/

COURSE: Practising Wisely - Reducing Unnecessary Testing and Treatment

When I speak to peers and clinicians, one of the most frequent bits of feedback I receive is "Great! I'm on board with delivering more appropriate care, Choosing Wisely, making sure my patients make shared decisions and avoid unnecessary tests and treatments. But... I don't really know how to 'do' it. Where do I start? How to I talk to patients? Where do I go to practice?"

So, it is with extreme pleasure that I announce the expansion of the Practicing Wisely: Reducing Unnecessary Testing and Treatment Course. Originally "Don't just do something, Stand there!," this highly-regarded hands-on learning experience was started by the Ontario College of Family Physicians and is spearheaded by Dr Jennifer Young.

It is now a suite of continuing professional development opportunities for primary care providers, available in a modular format across the country. In the course: 

Participants will identify opportunities to "practise wisely", with a focus on reducing over-prescribing, over-imaging, over-screening and over-monitoring using the latest evidence and tools from diverse sources. This workshop aligns closely with the Choosing Wisely Canada (CWC) campaign to implement good healthcare stewardship and avoid over-medicalization.

The program centres on case studies and incorporates individual reflection and group work. It helps participants to build communication skills to guide their patients through the shift from seeking sickness to enhancing health.


After active engagement in this program, participants will be better able to:

  • Identify opportunities to reduce “too much medicine”
  • Access and assess reliable, renewing online resources
  • Integrate relevant evidence into individual patient care
  • Communicate and build consensus with patients to reduce over-medicalization

    Upcoming Workshops are taking place as follows:

    May 24/17 - Montreal
    May 29/17 - Ottawa
    June 3/17 - Newfoundland
    Nov 22/17 - Toronto

    Find out more about the Practising Wisely program by viewing the main website or reading through this Q&A with Course Director, Dr. Jennifer Young.

    Source: http://ocfp.on.ca/cpd/practising-wisely

    VIDEO: #ChoosingWisely in Cypress Health Region

    Since 2015, The Saskatchewan Health Quality Council has been moving forward the very important agenda of Appropriateness of Care.

     

    In partnership with the Saskatchewan Medical Association, they have now launched Choosing Wisely Saskatchewan and are working engaging patients, clinicians, and learners to implement a province-wide strategy to tackle overuse. To start, they are focussing on pre-operative testing and imaging of lower back pain, and some of the health regions are taking on their own projects.

    The Cypress Health Region has demonstrated their commitment to Choose Wisely:

    Here's hoping many people will see their example and make the same pledge to choose wisely - because more is not always better in healthcare.

    Source: https://www.youtube.com/watch?v=gkqKRYpKbQ...

    Taking Action on Overuse: A Framework for Change (for Health Orgs & Institutes)

    It has been a while since I discovered any new organizations doing work on the topic of overdiagnosis and the related issues of overtesting and overtreating. Many different projects and initiatives explore the subject; some, like Choosing Wisely, make lists of 'do not do' recommendations. Others, like Minimally Disruptive Medicine provide thoughtful reflection and model practices to show us how to burden our patients less and engage them more. The Lown Institute and their Right Care Alliance work at many levels, be it in political advocacy, cultural change, or clinical education. 

    The Right Care Alliance is sponsored by the Robert Wood Johnson Foundation, something it has in common with Taking Action on Overuse.  While the former is more directed at patients, clinicians, and policy-makers, Taking Action on Overuse is a group that seems devoted to supporting health organizations and institutions. Organizations interested in creating changes to provide fewer unnecessary or harmful tests, treatments, and procedures, can employ the tools Taking Action has created. 

    In their words, "Taking Action on Overuse is an evolving framework for health care organizations to engage their care teams in reducing low-value, unnecessary care and make those efforts last. It identifies evidence-based strategies for obtaining buy-in, motivating behavior changes, and providing the necessary support and infrastructure for health care providers to engage and lead their peers in making the changes that improve the value of health care."

    Their Assessment can help you figure out whether your institution is ready with best practices, and gently guide you there. Likewise, their Framework can help you create the right conditions for change in a climate where many still believe "more is always better."

    Check out their website here to learn more.

    Source: https://takingactiononoveruse.org/

    A national discussion on unnecessary care #ChoosingWisely #Canada

    I am sharing this in case it has not made the rounds. The Canadian Institute for Health Information (CIHI)/Choosing Wisely Canada (CWC) report, Unnecessary Care in Canada, should be available in April. In the meantime you can read briefly about CIHI's role with CWChere.

    (Original post)


    A National Discussion: Unnecessary Care in Canada

    The Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada (CWC) invite you to join us for a discussion on the extent of unnecessary care in Canada.

    This webinar will introduce a new CIHI/CWC report, Unnecessary Care in Canada, and facilitate a conversation about the magnitude of and variation in unnecessary care across several areas covered by CWC’s recommendations.

    The event will include

    • A moderated panel discussion with:
      • David O’Toole, President and CEO, CIHI;
      • Dr. Wendy Levinson, Chair and Co-Founder, CWC; and
      • Dr. Laurent Marcoux, President-Elect, Canadian Medical Association
    • Speakers from the Canadian Partnership Against Cancer, North York General Hospital and other organizations, who will share their success stories about addressing unnecessary care
    • Q & A session

    Date: April 6, 2017
    Time: 9 to 10:30 a.m. ET

    Please note that this webinar will be conducted in English only and will use Eastern Time. To accommodate multiple time zones, a recorded copy of the webinar will be made available. When you register, please specify if you would like the recorded version.

    Registration: To participate, you must have access to the internet, as well as speakers/headphones. The webinar will be accessible on iOS and Android devices (both mobile phones and tablets).

    To register for the webinar, please email Alison Clement at aclement@cihi.ca

    How do you know? Fact, fiction, alternative truth?

    Humanity has explored many ways of knowing, from trusting deities and their 'earthly conduits,' to seeking out experts, to looking for evidence and statistics, to believing what one feels is 'right.' I am fascinated by epistemology (the investigation of how we know things, of what distinguishes justified belief from opinion) and the psychology of choice, but I am even more interested in what we can do to promote critical thinking.

     

    How do you raise children to question the statements that they hear?

    How do you inspire patients to develop their health literacy and explore how probabilities are presented to them?

    How do you convince policy-makers to consider value rather than throughput in their decision-making?

    Can we convince health 'experts' to include effectiveness, the risks, and costs of various interventions when they write guidelines?

    Apparently the heat from climate change has fried our leader's critical-thinking brain centres, and we now find ourselves awkwardly in an era of supposed "alternative facts." We know that fighting firmly held personal beliefs (even if we consider them lies and delusions) with facts is not effective; however, if you a reading this then you are already probably a bit skeptical, and you can explore the resources below to help with your own decision-making.

     

    HERE ARE A HANDFUL OF PUBLICLY-AVAILABLE TOOLS TO HELP:

     

    1) A book: Know Your Chances - Woloshin, Schwartz, Welch - FREE Online via PubMed

    Every day we are bombarded by television ads, public service announcements, and media reports warning of dire risks to our health and offering solutions to help us lower those risks. But many of these messages are incomplete, misleading, or exaggerated, leaving the average person misinformed and confused. Know Your Chances is a lively, accessible, and carefully researched book that can help consumers sort through this daily barrage by teaching them how to interpret the numbers behind the messages. . . The book's easy-to-understand charts will help ordinary people put their health concerns into perspective.This short, reader-friendly volume will foster communication between patients and doctors and provide the basic critical-thinking skills necessary for navigating today's confusing health landscape.

    [some other books about overtesting, overtreatment, and being skeptical in medicine are listed HERE]


    2) A video: How to spot fake news

    This video highlights the need to be skeptical and question headlines on social media or on other sites; it's sometimes hard to tell if a story is fake. If something seems shocking or strange, it's a good idea to ask around and do a bit of google-sleuthing. Checking the date, the source, and asking a skeptical friend can help you figure it out.
     

    3) A website: Testing Treatments Interactive

    The TTi site contains learning resources to help people recognise and understand Key Concepts, and how use them to evaluate treatment claims. These are categorized by concept, target learning group (kids, undergraduate students, etc), and the format (videos, websites, cartoons, etc). The book is also free and available in audio, PDF, or HTML format.

    4) A guide: 12 Questions to Ask: How to Evaluate Health Information on the Internet

    The National Institutes of Health has put together a great tool to help patients and caregivers check the reliability if information from the internet. These 12 straightforward questions can help you decide if what you are reading is useful - or useless.

    Do you have other tips for getting to the truth? 

    Source: https://www.amazon.ca/Know-Your-Chances-Un...

    FACTS & MYTHS: Prevent and Treat Cancer with Diet and Lifestyle

    Families, doctors, nurses, patients, people all:

    Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.

    Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.

    There are things you can do to lower your risks, robustly backed by the evidence: 

    • Avoid smoking
    • Exercise regularly
    • Stay away from environmental/industrial carcinogens like asbestos, radon, and benzene
    • Reduce radiation exposure by avoiding unnecessary medical imaging tests
    • Avoid excesses of alcohol
    • Wear sunscreen
    • Consider a pap test
    • Only take supplemental hormones if medically required
    • Get other 'screening' tests eg. colonscopy if you are a high-risk patient (eg. an immediate relation was diagnosed with colon cancer)

    There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.

    As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.

    Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.

    Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.

    In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:

    • Eating whatever you want
      • to try to slow the process of weight loss from cancer and to enjoy life because food = joy for many
    • Using money to enjoy experiences that are important to you 
      • visiting family, ticking items off the bucket list... one incredible patient I met shocked his family and had an incredible time by skydiving for the first time after age 70 (despite cancer with metastases to bone!)
    • Focusing on treatments that have been shown to be effective through scientific study
      • nothing breaks a caregiver's heart more than seeing someone chose an 'alternative' treatment when there is a validated one that would likely be well tolerated, and is quite likely to lead to cure (eg. death of Makalya Sault, after her family got their hopes ensnared by a quack in Florida
    • Working through the difficult task of coming to terms with having cancer, whether treatable or not
    • Receiving palliative care (which improves quality of life and can actually extend life!)

    Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.

    --

    Learn more about Tackling cancer treatment myths, from clean eating to cannabis

    Source: https://www.theguardian.com/science/blog/2...

    A Decision Aid: Goals of Care for Patients with Dementia #SDM

    There was an excellent paper in JAMA Internal Medicine (FULL TEXT), "Effect of the Goals of Care Intervention for Advanced Dementia" that was ePublished in November and is now in print. Dr Laura Hanson, at the University of North Carolina at Chapel Hill, and her colleagues were, in short, exploring the following:

    Question  Can a decision aid intervention about goals of care improve communication, decision-making, and palliative care for patients with advanced dementia?

    Findings  In this randomized trial of 302 nursing home residents with advanced dementia, family decision makers reported better end-of-life communication with clinicians. Clinicians were more likely to address palliative care in treatment plans, use Medical Orders for Scope of Treatment, and less likely to send patients to the hospital.

    Meaning  The goals of care decision aid intervention is effective in improving quality of communication, palliative care treatment plans, and reducing hospitalization rates for nursing home residents with advanced dementia.

    I wrote Dr Hanson who kindly provided a link to their decision aid video. It is 21 minutes, so the best way to use it might be to email it or set up a computer for family members so they can view it when a patient is admitted to a long term care facility.

     

    This video has been added to the Hands On Aids part of the Less is More Medicine site, where you will find lots of other shared decision-making tools.

     

    Hanson LC, Zimmerman S, Song M-K, Lin F-C, Rosemond C, Carey TS, et al. Effect of the Goals of Care Intervention for Advanced Dementia. JAMA Internal Medicine. 2017; 177(1):24-31

     

    Source: https://www.med.unc.edu/pcare/resources/go...

    DON'Ts for Long Term Care Patients: #ChoosingWisely Canada

    I have been a serious fan and also a concerned critic of Choosing Wisely Canada (CWC) over the years. Overall the campaign is excellent, encouraging conversations between patients and providers to help prevent harmful and unnecessary tests, treatments, and procedures.

    While I love the new emphasis on the high-level message "More is not always better," my feelings have always been lukewarm on the lists of Choosing Wisely Canada (CWC) recommendations, created by (mostly) physician associations not by Choosing Wisely Canada, as they vary in strength, currency, and courage. For example, the CAEP (Emergency physicians) list is quite clear, direct, and practice changing. The Orthopedics list is irrelevant, and not wisely chosen at all, lacking the moral fortitude to tackle common, high-paying procedures that have limited/no evidence to support them.

    The most recent lists reinvigorate my interest! It is exciting to see a list from the Canadian Nurses Association (CNA), as nurses have an incredible role in advocating for patients and in helping patients make decisions. Hospital-based nurses usually know their patients well and might even have a better sense of their goals and needs than would a physician; a nurse's advice can easily sway a patient to see "too much" medicine, but it can equally reassure that patient that a test or other intervention may not be right for them.

    Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

    Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

    Because most mornings I work in a program that is designed to help frail elders avoid unnecessary/ unwanted admissions to hospital, the Choosing Wisely list for Long Term Care (LTC) is extremely relevant to my practice. #1 (see below) resonates particularly with me, so I'm glad to see it is the first on the list. I see countless patients who could (and should) be looked after in their full-care facility but unfortunately they have turned up at the hospital. There are a number of reasons this happens, including the inability of the facility to contact the GP or the GP's inability to attend the patient in an urgent fashion, the family's 'insistence' that the patient be "checked out" at the hospital, a lack of clarity on the patient's goals, unclear understanding of the natural history of their disease, insufficient staffing at the care facility, etc. And sometimes these patients really do need to be at the hospital.

    We clearly have a lot to learn both in how we communicate and in how we approach care for patients in long term care. This list is a great addition to the tool kit that might help us give LTC patients the right care for them:

    1. Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.

    2. Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia. 

    3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).

    4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat. 

    5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient. 

    6. Don’t order screening or routine chronic disease testing just because a blood draw is being done.
       

    See the list here or download the PDF.

    Source: http://choosingwiselycanada.org/recommenda...

    JUST RELEASED: #RightCare Series in The Lancet

    The Lown Institute has just announced the release of the Right Care Series, a collection of articles on overuse and underuse of medical care around the world, published in The Lancet:

    "The full series of papers is available free to read online, along with our authors' commentary, a commentary by Don Berwick, and an editorial by Richard Horton & Sabine Kleinert of The Lancet. [The hops is that] you'll share the papers with your colleagues and others you think might be interested. You can also participate in the ongoing conversation about the papers on social media, by following us on Twitter and using the hashtag #rightcare. . .

    The series is also a great opportunity to start a conversation about right care with friends and family. [They] have created a short explainer in non-technical language that lays out the key points from the article, including why it's crucial for patients and community advocates to take a leading role in decisions about how countries allocate their health resources."

    (taken from a release by Vikas Saini, President, Lown Institute)

    There are two other medical journals featuring similar collections: 

    I also collect articles from diverse sources here:

     

     

    Source: http://www.thelancet.com/series/right-care