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:

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...

The answer to everything wrong in health care

TOP Alberta has released a beautiful infographic Evidence Summary: The Benefits of Continuity in Primary Care, and the document also serves as an overview of the 112 publications they reviewed.

It speaks for itself. Maybe the title of this post is a bit grandiose, but as a shameful hypocrite [I have very little continuity in my clinical practice, something I'm working to remedy] I cannot underscore how important this idea is.

Every physician, nurse, administrator (yes, you!), health policy person, and their uncle needs to not only know this but act on it. Continuity is what we need.

It's not a fad. It's something that we used to have. And it has slowly been eroded, without too many people noticing, as we kept focussing on the newest technology and the latest pharmaceuticals as if they would solve everything.

In BC, the essential nature of continuity has been recognized particularly with the work of Marcus Hollander and was implemented in the GP for Me/Attachment Initiative. Unfortunately (some might dispute this), changing physician incentives to try to encourage more attachment hasn't made much of a difference for patients. So while we know that we need continuity, we don't know how to 'make' the system or the providers do it.

It's a perfect storm for patients: Can't find a GP, or if you can it's hard to build a relationship with them because they are so busy/unavailable/don't have enough time to spend with you; the GP doesn't know all the details of your care as pharmacists/naturopaths and others expand their scope and don't communicate with the GP; the medical records at the hospital or from the specialist in the other city don't link with those of the GP so no one knows what is going on; when a referral or requisition is sent, there is no confirmation that is was received so it might be that you are just waiting, or it might be that it has been lost and you will never hear back about the appointment; when a home care support worker or nurse comes, it is a different person each day and they don't know you or your needs, and they aren't allowed to do the things you need help with most.

Health care really is about caring for people, and how can we do this when we do not build robust and lasting relationships?

The review did not cover provider satisfaction but personally and in BC studies so far, physician satisfaction is improved by continuity with patients. However, this is not how most young graduates are practicing; Yet another great reason that we need to look more into this.

Is it too good to be true? Before we rush ahead and try to force the "magic pill" of continuity, we need to know more about why it's being eroded, and if we can save it, then how?

 

Source: http://www.topalbertadoctors.org/file/top-...

Ten Commandments for patient-centred treatment | British Journal of General Practice

 One of James' slides from a talk we did with an older version of the commandments

One of James' slides from a talk we did with an older version of the commandments

I first encountered the 10 New Therapeutic Commandments when I started working with James McCormack on a lecture for medical students at the University of British Columbia.

Evolving from the chapter ‘The new therapeutics. Ten commandments’ by John S Yudkin in The Good GP Training Guide, they've developed into something completely wonderful.

I expect these capture the practice philosophy of most people who are interested in "Less is More" and "Choosing Wisely," and looking at them now, I think perhaps we should have devoted the entire lecture to this one slide.

See for yourself, the list and explanations, in the British Journal of General Practice.

 

My top 3 from the 10

1. Thou shalt have no aim except to help patients, according to the goals they wish to achieve

I think this could be the modern version of the most eminent aspect of the Hippocratic oath; not doing harm becomes respecting patient goals above all else)

2. Thou shalt always seek knowledge of the benefits, harms, and costs of treatment, and share this knowledge at all times

It is impossible to have an informed discussion and consent if one isn't informed.

7. Honour thy older patients, for although they often have the highest risk, they may also have the highest risk of harm from treatment

Exactly.

. . . 

Look at the list to see the rest!

 

Source: http://bjgp.org/content/65/639/532

The Most Important #ChoosingWisely List: Med Students & Trainees

Please join me in enthusiastically applying the latest Choosing Wisely Canada recommendations, as developed by the Canadian Federation of Medical Students (CFMS) and the Fédération médicale étudiante du Québec (FMEQ).

This amazing list of 6 items for Medical Students and Trainees to question is extremely important. It does a few things above and beyond what the other Choosing Wisely Canada lists could. Namely, the list:

  • Creates and promotes a culture of appropriateness in care early on in the careers of physicians, ensuring this way of thinking is embedded in their style of practice
  • Recognizes the professionalism, critical-thinking ability, and ethical intelligence of young clinicians
  • Engages medical educators and recognizes the mutual influence that learners and instructors can have on each other's practice
  • Is directed squarely at providers; while discussion between patient and provider may seem notably absent, each of the items is patient centred at a high-level; the list ensures that the goals of the patient – not the learner – are paramount, and that the learner will advocate in this regard

Hopefully the Students and Trainees Advocating for Resource Stewardship (STARS), students selected to champion the Choosing Wisely campaign, will be able to integrate these Top 6 into their medical schools' curricula.

Congratulations to the members of CFMS, FMEQ, and STARS on this fantastic work.

Review the 'Six Things Medical Students and Trainees Should Question' list.

Source: http://www.choosingwiselycanada.org/recomm...

Must Watch VIDEO: Intro to Too Much Medicine (ABC Catalyst)

28 minutes. That's all it will take to experience a fantastic overview of "too much medicine." 

Australian Broadcasting Commission (ABC)'s Catalyst has been able to clearly describe the problem, share common examples, offer opposing perspectives, and focus on some avenues for change. With guests like Dr Iona Heath (a retired GP and former President of Royal College of General Practitioners at the forefront of the movement to prevent overdiagnosis) and Dr Ranjana Srivastava (an oncologist, who wrote about the right amount of medicine in the context of her mother), it's persuasive, and it is for everyone:

  • newbies: patients and health care providers who are new to the concepts of "overdiagnosis," "overtreatment," and the idea that in medicine, sometimes more is not better will find this a decent introduction
  • keeners: this is an EXCELLENT video to use in your teaching and in spreading the message
  • skeptics: while this video may not persuade you to say "no" to having mammograms or stop ordering them for your patients, for example, it might help reframe the problem: 
    • the main idea is not "never do this test or treatment" but rather: we must combine the best available evidence about risks and benefits of having vs. or not having a test or treatment with the patient's goals, and currently we are doing a pretty bad job of fully informing our patients to empower them to make the choice that is appropriate for them


Go ahead!

 

Could our relentless pursuit of good health be making us sick? Advances in medicine have propelled health care to new heights and a vast array of diagnostic tests and drug therapies is now available. But are we getting too much of a good thing? An increasing number of doctors now say that sometimes, "less is more" when it comes to medical interventions. Some doctors are concerned that resources are being wasted on the "worried well" and that the ever-expanding definition of how we define "disease" has been influenced by vested interests. Could excessive medical interventions be causing more harm than good? Dr Maryanne Demasi examines how our relentless pursuit for good health might be making us sick

*NB if the youtube link doesn't let you view the video from your country, try ABC's website: http://www.abc.net.au/catalyst/stories/4339690.htm*

Want more? Australian media is just knocking it out of the park! ABC's Four Corners did a similar video, Wasted that is also worth a look.

Source: http://www.abc.net.au/catalyst/stories/433...

VIDEO: Wasted: Waste and Harm and Unnecessary Tests (Four Corners)

In just 45 minutes, the problem of overdiagnosis, overtesting, and overtreatment is clearly summarized using examples from the Australian system. The costs and harms to patients are incredible, and an analogy – taking the wrong train and winding up where you never intended – is an effective illustration of the issues.

Some key messages:

Billions of dollars are spent on procedures that are not needed, simply because patients expect them and because doctors continue to lobby to be paid to do their 'favourite' procedures.

What is your estimate of how many of those knee arthroscopies are unnecessary? - Dr Normal Swann, Interviewer
Uh, I would say, at least half. - Dr. Ian Harris, orthopedic surgeon

This is no surprise. Dr James Rickert has been advocating for more appropriate care in orthopaedics, for example with an alternative Choosing Wisely list  (despite what the article says, not just 'one guy's opinion' but rather a summary based on the best available evidence, presented most recently at Preventing Overdiagnosis), for years. But conflict of interest, particularly in industry lobbying and influence in the creation of guidelines, continues to be a problem. So does fee-for-service payment systems which encourage higher throughput rather than best care. 

There are other pressures too:

Often the best medicine is no medicine at all, or the best intervention is no intervention at all. But those conversations with patients that take that time to explain that the evidence simply doesn't support doing a test or prescribing a drug  - are long conversations and it's much easier in clinical practice to do things quickly and prescribe or order a test. - Dr Rachelle Buchbinder, rheumatologist

 

Patients and physicians are both uncomfortable with uncertainty, so tests 'just to see,' continue to be ordered, despite the evidence that they are needless and carry risks. We need to realign expectations, save the waste, and re-direct it into areas of health care that will really help people instead of harming them.

Watch the video for more cutting commentary and alarming statistics.

 

FULL VIDEO: FOUR CORNERS: WASTED

TEASER: 


Source: http://www.abc.net.au/4corners/stories/201...

Less is more, InVivo Magazine

  in Vivo Magazine

in Vivo Magazine

In the spring, I had the pleasure of being one of many people interviewed by Julie Zaugg for In Vivo Magazine.

Their sixth issue featured Less is More with data and opinions from mainly Swiss physicians and researchers. 

From the by-line, it seems they've missed the idea entirely

People are beginning to speak out against over-medialization. Measures are being taken to encourage less care, even if that means giving up old certainties.

That sounds like doing less is a terrible idea! Fortunately, the article comprehensively features the benefits of taking this approach to care. Comfort with uncertainty is one trait that can make a good physician great. That piece explores the state of the 'overmedicalised world,' the causes for it, and what some of the remedies might be. My emphasis? Patient-centred care.

You can see the article here, or explore the whole issue on Issu. If you'd like to see other interviews, articles, or talks I have participated in, check out the Media section.

 

It was wonderful to be a small part of the article and because of my involvement, I learned about "Smarter Medicine," a Swiss campaign [in German and French] similar to Choosing Wisely;  I have a feeling that they two will be integrated in time. This and other projects around the world are featured on the ever-growing Projects page.

 

 

Source: http://www.invivomagazine.com/en/focus/chr...

MUST WATCH: Ain't the Way to Die (@ZDoggMD)

Watch this. Share this.

ZDoggMD (Dr Zubin Damania), once a hospitalist, now a primary care revolutionary with his Turntable Health project, has always made hilarious videos about life as a physician, the patients we see, and the culture of medicine.

Below is his most poignant piece, revealing the difficulties of end-of-life conversations and medical futility both from the patient and the physician perspective. It's not corny or cheesy. It is bang-on.

"Ain't the Way to Die" (a parody of Love the Way You Lie, by Eminem and Rihanna) is so scarily accurate. The same problems he sings about are what I wrote about in "I QUIT! Will the law force us to provide futile, harmful care?"

I have not quit medicine, probably because there are people out there like Dr Damania who understand exactly what it's like to be asked to prolong someone's suffering.

I've never been able to relate to the angst expressed in a rap before, I guess because I don't have a lot of angst. But this video takes the words right out of my mouth, highlights all the heavy-sigh moments of these conversations - it's time to call the family, the relative in another country who says "he'll wake up," or the conflict in the family between ones who know he would not want to be a vegetable and the others who are holding on out of guilt or fear.


The vent-bucking sounds and monitor bleeps incorporated into the end of the song squeeze the adrenals.

Do watch. 

4 minutes could not be better spent.

Lyrics: “Ain’t The Way To Die”

Based on “Love The Way You Lie” by Eminem and Rihanna

Just gonna stand there and watch me burn
End of life and all my wishes go unheard
They just prolong me and don’t ask why
It’s not right because this ain’t the way to die, ain’t the way to die

Patient:
I can’t tell you what I really want
You can only guess what it feels like
And right now it’s a steel knife in my windpipe
I can’t breathe but ya still fight ‘cause ya can fight
Long as the wrong’s done right—protocol’s tight
High off of drugs, try to sedate
I’m like a pincushion, I hate it, the more I suffer
I suffocate
And right before I’m about to die, you resuscitate me
You think you’ve saved me, and I hate it, wait…
Let me go, I’m leaving you—no I ain’t
Tube is out, you put it right back, here we go again
It’s so insane, ’cause though you think it’s good, I’m so in pain
I’m more machine than man now, I’m Anakin
But no advanced directive, I feel so ashamed
And, crap, who’s that nurse? I don’t even know her name
You lay hands on me, to prolong my life again
I guess you must think that this is livin’…
Just gonna stand there and watch me burn
End of life and all my wishes go unheard
They just prolong me and don’t ask why
It’s my right to choose the way that I should die

Doctor:
You ever love somebody so much, you can barely see when you with ‘em
That they, lay sick and dying but you just don’t wanna let ‘em
Be at peace cause you miss ‘em already and they ain’t gone
Beep beep, the ventilator alarms
I swore I’d never harm ‘em, never do nothing to hurt ‘em
Hippocratic oath primum non nocere now I’m forced just to torture ‘em
They push full code, no one knows what his wishes were
His sister heard him say once, “I don’t wanna be a vegetable”
But no one agrees in the family, his caregiver Kate
Wants him comfort care but Aunt Claire lives so far away
That her guilt eats her like cancer
So she answers, “Wait! I think he’ll wake”
Maam, you ain’t even in the state!
Palliate, relieve pain, get him home, explain
Critical care? Just hypocritical when it’s so insane
But they insist I shock his heart again so I persist
Guess that’s why they say that love is pain.
Just gonna stand there and watch me burn
End of life and all my wishes go unheard
They just prolong me and don’t ask why
It’s my right to choose the way that I should die
The way that I should die


Source: http://zdoggmd.com/aint-the-way-to-die/

Quaternary Prevention, P4

We still lack a unifying name, but initiatives like "Right Care," "Choosing Wisely," "Preventing Overdiagnosis," "Prudent Healthcare," and others all seek to describe, categorize, confront, or improve upon the status quo of what's being done: too much medical stuff and too little caring for people.

   
  
 
  
    
  
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    Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

 

Quaternary Prevention

You may have read lately about Quaternary Prevention (Prévention quaternaire) or P4, a major initiative of this movement. This – in the words of Ray Moynihan – "awkwardly titled" idea came originally from Dr Marc Jamoulle (@jamoulle), a Belgian GP, almost 30 years ago.

He coined the term "Quaternary Prevention" to describe 'an action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are ethically acceptable.' Essentially, it is a process that explicitly considers and thus enables avoidance of iatrogenic harm. 

"Quaternary prevention should take precedence over any alternative preventive, diagnostic and therapeutic, as dictated by the principle of primum non nocere." (Wikipedia)

P4

*NB*: Be careful not to confuse Jamoulle's term P4 with the more popular P4; predictive, preventive, personalized, and participatory (P4) medicine, with a focus on detecting and dealing with disease before it even exists, may (arguably) be the antithesis to Quaternary Prevention.

Jamoulle's idea came first, anyway. His original 1986 article Information and computerization in general practice (en français) started the discussion around quaternary prevention, with a particular focus on how information technology can dehumanize healthcare. He has refined the idea, with presentations at WONCA world conferences and many publications (listed here).

View Dr Jamoulle's page on Quaternary Prevention "P4" or read more

Although the cumbersome title will probably dissuade related initiatives from taking the name and falling under the umbrella of 'quaternary prevention,' we are all united in the spirit of our efforts. I remain in awe that Jamoulle and others had the wisdom to begin the discussion of harms of overdiagnosis in a time while mammography was just gaining momentum, ADD was rarely diagnosed and yet to be redefined as ADHD, and I was still in diapers.