The Case for Being a Medical Conservative

Drs Vinay Prasad, John Madrola, Adam Cifu, and Andrew Foy have written a fantastic article about what they call “Medical Conservatism.” Read it HERE

I never thought that those in the movement to prevent overdiagnosis/medicalization and overtreatment would be labeled as “conservative” in our thinking - but I identify directly with many aspect of this article.

I am proud to work with an organization (The Therapeutics Initiative) which does rigorous, unconflicted review of the medical evidence. Many (but not all ) of our conclusions are essentially that the drugs don’t work as well as we wish they did. And for coming to these conclusions, we have been called nihilists.

Like anyone, I want the medications to work, and work well. Yet, I understand that they often do not, and that we need to stop pretending that they might kinda sorta a little, when the evidence says that they (sadly) really don’t make a meaningful different for outcomes that matter to patients. This can be hard to reconcile in clinical practice where clinicians and patients alike get stuck on the hope of success in the face of illness and adversity.

The authors explain there terminology further:

Our choice of the term medical conservative does not imply a political philosophy, although William Buckley Jr.'s definition of conservatism aligns well with our approach to patient care:

“A conservative is someone who stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it.1

Here is what we believe:

Medical conservatives are not nihilists. We appreciate progress and laud scientific gains that have transformed once deadly diseases, such as AIDS and many forms of cancer, into manageable chronic conditions. And in public health, we recognize that reducing exposure to tobacco smoke and removal of trans-fats from the food supply have contributed to the secular decline in cardiac event rates.2 Indeed, medical science has made this era a great time to live.

The medical conservative, however, recognizes that many developments promoted as medical advances offer, at best, marginal benefits. We do not ignore value. . . . The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased. 

In the article, they show this graph, comparing the magnitude of benefit for a patient to the cost of the care, with some examples:

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The area on the left is where we want to be. The “A” items make a really really big differnce for people’s well being. Not surprisingly, a lot of the modifiable social determinants of health live in “A” territory. The trouble is the “C” territory, the things that we do that make basically no impact for patients but that cost an extraordinary amount in terms of harms, burden, and financial measures for patients and society.

My colleague Juan Gérvas said it well when he wrote our ‘preventing overdiagnosis’ mailing list: “the end of the curve is not flat, but going down... [at that point, the] harms outweigh benefits.; on the end of the flat part of the curve, additional spending, whether it be on a new drug, device or diagnostic test, confers more harms than benefits to individual patients or society".

QUIZ: How well do you think about risk and uncertainty?

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Understanding the risks and benefits of all options is critical for effective decision-making. Those who are comfortable with uncertainty and who understand the magnitude of risks tend to excel with decision-making in health, finance, and other high-stakes fields.  By taking the time to consider a problem and engage in self-reflection, more sound decisions can be taken - but a foundation that includes statistical literacy is also required.

The very basic understanding of risk and uncertainty apparently leads you to become more reflective about the information you consume, creating a more rational and informed worldview. In technical terms, it seems to increase your “metacognition” – your capacity to question your own reasoning and judgements.
— Predicting biases in very highly educated samples: Numeracy and metacognition - http://journal.sjdm.org/13/13919/jdm13919.pdf

Many of my peers in the overdiagnosis community are professionally skeptical. These patients, clinicians, and researchers tend to ask questions like: "is that really what the data show?" "how do we know this?" "through what lens was this interpreted, are there any biases?" It is because of this type of reflection that they can distance themselves from the evidence and view it critically. It is not surprising, given our interests, that members of our community score highly on the Berlin Numeracy Test.

Curious about your performance? Test your risk literacy now.

Read the original BBC Article:  How well do you think about risk and uncertainty? for more.

While historically health care providers and administrators have been preoccupied with people underestimating risk, there are profound implications of low statistical numeracy and risk literacy for overtesting/treatment and diagnosis.

These skills are of even greater importance today. “Nowadays patients are expected to make decisions, and they are given much more information than in the past,” [Valerie Reyna] says. You might be given more data about the side effects of different drugs, for instance, when choosing a treatment option – a little like the example question above. Or imagine you have taken a test that reveals a genetic predisposition to certain kinds of cancer. Misinterpreting the risk could lead you to needlessly undergo surgery. “We want patients to be empowered to make decisions – but now that means the burden is on them to understand a lot more technical information, so that makes it particularly important that they are numerate and literate.

Should we enhance risk evaluation and statistical skills education in high schools? What differences would we see in our society if the majority of people had an increased capacity to question their own reasoning and judgements?

Source: http://www.bbc.com/future/story/20180814-h...

Top POEMs of 2017 Consistent with Principles of the Choosing Wisely Campaign

Dr Roland Grad is back again with another persuasive publication regarding POEMs that align with principles of the Choosing Wisely campaign.

I find that infoPOEMs are a quick way to learn about new developments in practice and many of the topics align well with my interest in avoiding unnecessary and harmful care. Drs Grad and Bell have reviewed last year's POEMs with that lens, and their paper offers a great source of input for Choosing Wisely recommendations, as well as a launching point for changing your own practice.

Dr Grad will be presenting the poster at the Preventing Overdiagnosis 2018 conference in Copenhagen.

A POEM is a synopsis of a research study that reports patient-oriented outcomes, such as improvement in symptoms, quality of life, or mortality; is free of important methodologic bias; and recommends a change in practice for many physicians. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for physician-members of the Canadian Medical Association. . . . The recommendations cover musculoskeletal conditions (e.g., avoid arthroscopy for initial treatment of a meniscal tear), respiratory disease (e.g., avoid screening for lung cancer without informing your patient of the risk of a false-positive test result), infections (e.g., do not routinely add trimethoprim/sulfamethoxazole to cephalexin for nonpurulent uncomplicated cellulitis), and cardiovascular disease (e.g., do not prescribe niacin, alone or in combination with a statin, to prevent cardiovascular disease). These POEMs describe interventions whose benefits are not superior to other options, are sometimes more expensive, or put patients at increased risk of harm. Knowing more about these POEMs and their connection with the Choosing Wisely campaign will help clinicians and their patients engage in conversations that are better informed by high-quality evidence.

You can read the full publication here, in AFP.

Previous contribution from Dr Grad and colleagues to this blog can be found here:

 

The 3rd Era of Health Care - Don Berwick

Having just returned from the Choosing Wisely Canada national meeting in Toronto, I was reflecting on what I learned. There was much inspiration and practical suggestions around implementing and sustaining quality improvement, and some of these learnings will change my practice. 

I was also re-invigorated by the energy of the Students and Trainees Advocating for Resource Stewardship (STARS), and reassured by the Canadian Medical Protective Association's endorsement of the Choosing Wisely campaign.

Dr Dee Mangin delivered a compelling, philosophical keynote to close the conference; she explored the issues driving medicalization and polypharmacy, and offered some hope for taking action against these. There were many reality checks for the audience, and recent research on physician behaviours, publication biases, a society obsessed with risk surprised many. Some of this was very familiar to me from discussions and presentations within the Preventing Overdiagnosis community, but Dr Mangin has a way of explaining things in such a way that their profound nature hits you like a tonne of bricks. (This is a good thing!)

It was clear at the conference that things have to change. But what is that vision, exactly?

One idea that was new to me was that of the "3rd Era of Heath Care," a concept developed by Dr Don Berwick, of the Institute for Healthcare Improvement (IHI). Dr Mangin touched on it and I think it's an idea worth sharing:

THESIS: Preventing Overdiagnosis, the Quaternary Prevention

Maria Llargués Pou, a soon-to-be Family Physician in Barcelona, recently shared with me her Bachelor's Thesis. 

Her work - "Primum non nocere" Preventing Overdiagnosis, the Quaternary Prevention provides a concise introduction to the efforts around the world to prevent overuse of tests, treatments, and disease-labels, as well as the reasons we must address this growing issue.

 

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy 

Llargués Pou has beautifully laid out an evolution of ideas, from Ivan Illich's idea of Iatrogenesis, to Jamoulle's attempts to thwart iatrogenic harm with a public health model of Quaternary Prevention, and now, contemporary efforts to tackle overdiagnosis, like the Choosing Wisely Campaign and Preventing Overdiagnosis conference. Her paper serves as a great "backgrounder" for those who wish to learn more about the broad themes and history of this movement.


You can view the full text HERE.

Overdiagnosis across medical disciplines: a scoping review | BMJ Open

Curious about which areas of medicine have more problems with overdiagnosis than others? Wondering in which fields the problem has been studied extensively? A group from the Netherlands has looked into this extensively in their paper: Overdiagnosis across medical disciplines: a scoping review for BMJ Open.

One of the biggest challenges in exploring this area is that the problem of 'too much medicine' goes by many different terms, these vary from place to place, and even where the same term is used there is disagreement about definitions. 

Jenniskens, a PhD student at Utrecht University, et al looked at almost 5000 studies and included 1581 for review. Unsurprisingly, the majority of papers pertained to the field of oncology, perhaps because wide-spread screening programs and attempts for early diagnosis are much more common for cancer than for chronic disease and other conditions. Though they did not publish the information, they also took a moment to determine from where in the world the papers were being written.

For years, I have been fascinated with the geographically diverse response to the problem of overdiagnosis and the idea that overdiagnosis can happen in resource-rich and -poor countries alike. I worked with Alan Cassels to facilitate a group discussion at the Preventing Overdiagnosis conference in Barcelona in 2016. We identified movements that attempt to combat overuse of tests, treatments, and procedures around the world (presentation slides are available here) and discussed what factors in each region might be playing a role.

Seeing that presentation and recognizing my interest, Mr Jenniskens has since kindly provided me with a breakdown of the country of origin of the authors for the papers analyzed in his group's review. While most of the papers were tied to the United States, first authors from 65 different countries were among the 1581 papers.

Grey - no authors; Light Green - few authors; Orange - many authors.

Grey - no authors; Light Green - few authors; Orange - many authors.

Please click through to interactive map to view the % proportion of authors of the 1581 assessed papers, originating from each country. From Albania to Zimbabwe, it is clear that overdiagnosis is a global concern, and is being researched everywhere.

Read more about the papers considered in the scoping review.

Source: http://bmjopen.bmj.com/content/7/12/e01844...

Resource Stewardship Toolkit - for education of resident physicians

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Over the past year, I had the opportunity to contribute to the formation of several toolkits on the topic of "Resource Stewardship." These toolkits were created by the Royal College of Physicians and Surgeons of Canada (RCPSC) in partnership with Choosing Wisely Canada and the College of Family Physicians of Canada (CFPC).

The aim was to create modules that educators could use in order to encourage residents to be mindful of overdiagnosis, overtesting, and overtreating as they prepare for practice. By empowering them to have conversations with patients about unnecessary medical interventions and to undertake Quality Improvement projects in this area, preceptors can ensure that physician trainees satisfy the societal duty (as well as a residency education CanMEDS requirement) to be good stewards.

There are THREE toolkits, each containing a powerpoint and preceptor guide:

  1. Foundations - basic information, vocabulary to facilitate residents becoming mindful of considering the (broad) harms and benefits of any test, treatment, or procedure.
  2. Projects - information and guidance on how to undertake a scholarly (eg. research or QI) project in this area
  3. Communication - scenarios, role play, and other resources to help residents communicate with patients and families who may request an unnecessary test, treatment, or procedure

You can find more education resources on the teaching page.

Source: http://www.royalcollege.ca/rcsite/canmeds/...

VIDEO: A troubling pharmaceutical cocktail | Dee Mangin #WalrusTalks

Polypharmacy-smashing superstar Dee Mangin delivered a compelling talk for The Walrus about the problem of too much medicine.

In just over 8 minutes, she beautifully articulates the issue and a vision of how we can address it.

Source: https://www.youtube.com/watch?v=QQkV7yHuQ-...

PODCAST: Preventing Overdiagnosis 2017 - from theory to practice by BMJ talk medicine

My first Podcast!

Dr Navjoyt Ladher of BMJ talk medicine kindly invited a few colleagues and me to participate in an informal discussion at the Preventing Overdiagnosis 2017 conference in Quebec, Canada.

As working clinicians, we explored moments in our careers that got us interested in tackling overdiagnosis, scratched our heads thinking a little bit about why we (and not all of our colleagues) are taking this on, and reflected on take away messages from the conference.

Have a listen, and go to the original site if you wish to join the discussion.

Source: https://soundcloud.com/bmjpodcasts/prevent...

VIDEO: The Truth about Mammograms - Adam Ruins Everything

Here's a great, brief explainer about the problems with mammography (and most cancer screening)  - 2:43

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Source: http://www.trutv.com/shows/adam-ruins-ever...