I love Healthcare Triage! VIDEO: Malpractice, Healthcare Costs, and Tort Reform

Dr Aaron Carroll (@aaronecarroll) & Co. are amazing!

Healthcare Triage (@HCTriage) has a YouTube channel that hosts a range of videos, most of which pertain to the "Less is More in Medicine" movement. The Less is More blog has featured their work before, 1) when Healthcare Triage did a video about Choosing Wisely, and 2) when Dr Carroll wrote Why Survival Rate Is Not the Best Way to Judge Cancer Spending for Upshot in the NY Times. In early June, they posted another great video, busting some major medico-legal myths.

One of the main excuses physicians make for ordering too many tests and treatments is that they have to practice defensive medicine. You must 'cover your ass' (CYA) to ensure nothing is missed, lest you face a horrible lawsuit. Physicians pay a ransom to malpractice insurance in order to help protect their reputation (and earnings) should a case come forward.

Many frivolous lawsuits exist and a lot of poor care is not legally pursued. Physicians think that tort reform will solve everything. Not so. Watch the video to learn more:

Source: https://www.youtube.com/watch?v=sK-E_d1MGt...

You'll hardly believe these 6 nerdy ideas! aka Buzzfeed's 'Misconceptions about Screening'

Yes, it's true, even the popular 'internet news media company' Buzzfeed is hosting an article highlighting the issues that arise with the current practice of disease screening. Known for horribly-titled and irrelevant news-utainment, with headlines like "The 21 Erotic Moments From The First Time You’re In A Bulk Barn," the site does have over 200 million viewers monthly. They must be doing something right, and hopefully this Buzzfeed Community post, Misconceptions about Screening, will be a viral hit, just like "These American Tourists Were Delightfully Puzzled By Awesome Canadian Road Signs."

In the post, Sense about Science, a UK-based organization that 'equips people to make sense of scientific and medical claims in public discussion,' wrote:

There’s a huge amount of discussion about screening programmes from celebrities, campaigners and emotive media case studies. Unfortunately, a lot of this discussion is filled with misconceptions, misinformation and unrealistic expectations of what screening programmes are and what they can deliver. This has real lasting implications for patients and healthcare professionals. This needs to stop.

They go on to review 6 key issues with broad-based screening campaigns, highlighting the grey areas in screening test results, the costs and harms of these tests, the different role they play as compared with diagnostic tests for symptomatic individuals, and the idea that screening must be employed only for the right population and the right diseases.

One of the Making Sense of Science infographics on the topic of screening.


One of the Making Sense of Science infographics on the topic of screening.

 

Much of the culture of screening has been created by the medical industry and by health care practitioners, but the celebrity 'experts' have not helped. This article reminds Buzzfeed readers, many of whom follow celebrity news, to think twice about listening to this unscreened advice.

Read Making Sense of Science's 'MAKING SENSE OF SCREENING: A guide to weighing up the benefits and harms.' Other similar tools can be found in the health care provider section, the patient section, and the 'hands-on' section (mostly tools for shared decision-making) on this site.

 

Source: http://www.buzzfeed.com/senseaboutscience/...

Doctors' grade: C- on #ChoosingWisely Test Your Knowledge Questions in CMAJ

Fascinating results emerge from a small online poll of Canadian Medical Association Journal (CMAJ) readers. Web polls on the CMAJ site were done over the span of 7 months and the following 12 True or False questions were asked.

Although not scientific, the results tell us that (at least mildly-) engaged physicians (those going to the CMAJ website) like to provide a lot of unnecessary and harmful care, particularly in the area of diagnostic imaging.

Not only do we need more research on why physicians think this way, we also need research on what methods are effective at changing behaviours. We don't know yet if Choosing Wisely-type outreach to patients and providers can improve practice. We think and hope so . . .

See the Choosing Wisely Canada update for more.

EDIT:

*NB: Dr S.P. Landry has a keen eye and noticed an error; for the item pertaining to "All children with head trauma require imaging to rule our fracture and brain injuries" the answer should be FALSE. So, the correct response rate would be 70% on that question, making the overall score of respondents a little less terrible, but still remarkably bad ;)


Source: http://www.choosingwiselycanada.org/news/2...

Rational test ordering in family medicine

It is typical in medical teaching to start an article or talk with a case.

What is not typical about about this Canadian Family Physician (CFP) article, written by Australians Drs S Morgan, M van Driel, J Coleman, and P Magin, is that the case is not meant to teach us how to do something. It is meant to challenge us, to teach us how NOT to do something.

When a 'routine annual health check' involves non-evidenced tests, and abnormal results are found, it leads to further testing; anxiety and other harmful effects of the testing cascade or treatments develop. This is the problem of overtesting and overdiagnosis.

It is best to not order irrational, unjustified tests "just to see" because there are harms of "just seeing." If you order enough tests, there will definitely be abnormal findings, many of which are spurious or clinically insignificant.

Many of those reading know this problem, but we are not always sure of the solutions. Morgan et al suggest and expand upon these mitigating steps:

  • Undertake a thorough clinical assessment
  • Consider the probability and implications of a positive test result
  • Practise patient-centred care
  • Follow clinical guidelines or seek other specialist guidance (*my caveat: if the guidelines are reasonable, free of industry bias, and appropriate for the patient in front of you)
  • Do not order tests to reassure the patient
  • Accept a degree of uncertainty
  • Use serial rather than parallel testing
  • Reflect and critically appraise test ordering

I like the list as it challenges some myths, like "ordering the test will make the patient feel better." Many of the drivers of overtesting explained here overlap with the Contributing Factors piece I'm working on, though I'm inspired that perhaps "taking time" (using a longitudinal relationship to slow down, to do serial testing, etc.) may need to be added to the list.

View the article in the CFP to read more.



Source: http://www.cfp.ca/content/61/6/535?etoc

VIDEO: Good Stewardship / Model conversations with patients about overtesting and overtreatment

The National Physician Alliance (NPA) has done a lot of work in the area of preventing overdiagnosis and empowering patients to find the right amount of care. They are a partner in the Tandem Health project/app, created Top 5 lists (in good stewardship) which served as a model for the Choosing Wisely Campaign, and promote responsible prescribing (by limiting influence of the pharmaceutical industru) through The Unbranded Doctor.

Created in 2011, this video is a timeless tool for Good Stewardship. It gives a simple, 5-step plan of how health care providers can discuss unnecessary tests and treatments with patients.

They suggest:

1. Clarify what the patient’s true concerns are
2. Provide the patient with the information he/she needs to understand the plan
3. Be courteous and respectful
4. Provide clear contingency plan
5. Make sure the patient is satisfied with the plan
Source: https://www.youtube.com/watch?v=kh7EKP9wSg...

Choosing Wisely Canada: 3rd Wave of Reccomendations

Choosing Wisely Canada has released their 3rd wave of recommendations!

Groups like the Canadian Association of Emergency Physicians (CAEP), Canadian Society of Hospital Medicine (CSHM), three psychiatry groups (Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association) and three surgical groups (Canadian Spine Society, Canadian Society for Vascular Surgery) have all developed lists of the top things that patients and doctors should question. The Canadian Society for Transfusion Medicine also added 5 new recommendations. See the new recommendations here.

This round was particularly interesting for me as I got to witness the process of the development of the CSHM list and participate in some stages, though not extensively. It's a tough task, whittling down all the ideas to find well-evidenced items that represent key areas for improvement, and try to avoid duplication of other specialty society recommendations. The group has to consider that many things which are good ideas and really really important to tackle, may not be suitable as the evidence behind them may be vague.

For example, though we all felt that discussing 'goals of care' or advance directives and resuscitation statuses (eg. DNR) with patients is very important, there's little data about why/how/when this should happen and what impact it actually has on patient well-being. Should it be discussed by the hospitalist? The GP? On all admissions? Only when a patient's status changes?

Ultimately it was impossible to make a firm statement that was robustly rooted in evidence, though our 'gut' feeling was strongly that we need to be having these discussions and that patients and doctors both should be starting conversations on the subject.

Choosing Wisely, as ever, forms a great starting place for discussing overuse of harmful and unnecessary tests and treatments. Yes, some of the recommendations are 'low-hanging fruit' but we have to start somewhere, and Choosing Wisely is great at getting us started talking about the facts that "more is not always better" in medicine.

Source: http://www.choosingwisely.ca

Choosing surgery wisely: the importance of evidence-based practice

* RESEARCH FIRST LOOK *

Very little research has been done so far in the area of appropriateness in health care, so it is is always a delight to see what is being worked on.

You may remember Roland Grad, a family physician and research at the University of McGill, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign.

Two ambitious McGill medical students, Nicholas Meti and Mathieu Rousseau, worked with Dr Grad to extend that work and look at InfoPOEMs that dealt specifically with surgical interventions which are considered unnecessary or harmful to patients.

Many agree that there's room for the Choosing Wisely campaign to improve; this research presents a potentially fruitful way to do so, particularly for the orthopaedics recommendations which have been heavily criticized to date.


Choosing surgery wisely: the importance of evidence-based practice

Meti, N., Rousseau, M., Grad, R. Medicine, McGill University, Montreal, Canada.

An emerging trend among physician organizations is to attempt to control or reduce the rate of unnecessary medical tests and treatments. Until recently, the principle manner to release updated recommendations for practice was through meetings where experts discussed which tests or treatments needed to be questioned.  

We developed a novel means of analyzing nascent research articles for their applicability towards improving the “Choosing Wisely” topic selection process [1]. This method is based on analyzing the ratings of daily POEMs, collected from physician members of the CMA. POEMs are tailored synopses of primary research or systematic reviews, selected by searching over 100 journals. POEMs are delivered to over 20,000 members of the Canadian Medical Association (CMA) by email on weekdays.

At the 2015 ‘Preventing Overdiagnosis’ conference, one of us (RG) will report on the top POEMs of 2014, as rated by CMA members with respect to their potential to help them to ‘avoid an unnecessary diagnostic test or treatment’ [1]. Of the topics addressed by these top 20 POEMs of 2014, only 2 were discussed in the Choosing Wisely master list of recommendations. Of the remaining 18 topics, three were related to surgical interventions; we highlight their important findings.

In a study published in The Bone and Joint Journal, Kukkonen et al. used the Constant Shoulder Score to show that among patients with symptomatic non-traumatic supraspinatus tears, physiotherapy alone is as effective as physiotherapy combined with acromioplasty after 1-year follow up [2].

In a study published in the New England Journal of Medicine, Sihvoven et al. investigated whether arthroscopic surgery would improve outcomes for select patients with a degenerative tear of the medial meniscus. The researchers conducted a multicenter, randomized, double-blind, sham-controlled trial involving patients without knee osteoarthritis, but with symptoms of a degenerative medial meniscus tear. Surgery was found to be ineffective for non-traumatic partial medial meniscus tears [3].

A study published in JAMA by Primrose et al. [4] questioned the routine practice of intensive follow-up after surgery for colorectal cancer, as there existed no evidence to support this common practice. In a randomized controlled trial, 1,202 participants were assigned to 4 groups: CEA only, CT only, CEA+CT, or minimum follow-up. Their results demonstrated that among patients who had undergone curative surgery for primary colorectal cancer: 1) intensive imaging or CEA screening each provided an increased rate of surgical treatment of recurrence with curative intent, compared with minimal follow-up; 2) there was no advantage in combining CEA and CT; and 3) there was no statistically significant survival advantage to any strategy.

One concern about the development of top five lists in Choosing Wisely is the potential for individual specialties to choose the low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included no major surgical procedures in their top 5 list, despite evidence of wide variation in elective knee replacement and arthroscopy rates [5]. This observation is not meant to be a criticism of orthopedic surgeons per se, as many surgeons are strong advocates for their patients (see http://www.thepatientfirst.org). [Less is More readers will remember one of the founders, Dr James Rickert, from What Can Patients Do in the Face of Physician Conflict of Interest]

Our point is to drive home the underlying philosophy of the “Choosing Wisely” campaign: ‘routine’ testing or treatment without evidence-based support can be found insidiously entrenched in all disciplines.


References

1. Grad RM, Pluye P, Shulha M, Tang DL. POEMs Reveal Candidate Clinical Topics for the Choosing Wisely Campaign. Preventing Overdiagnosis Conference, Bethesda, MD, September 2015.

2. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014; 96(1):75-81.  
http://www.ncbi.nlm.nih.gov/pubmed/24395315

3. Sihvonen R, Paavola M, Malmivaara A, et al., for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369(26):2515-2524.    http://www.nejm.org/doi/full/10.1056/NEJMoa1305189

4. Primrose JN, Perera R, Gray A, et al., for the FACS Trial Investigators. Effect of 3 to 5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer. The FACS randomized clinical trial. JAMA 2014; 311(3): 263-270. 
http://www.ncbi.nlm.nih.gov/pubmed/24430319

5. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—the politics and economics of labeling low-value service. N Engl J Med 2014; 370:589-92. 
http://www.nejm.org/doi/full/10.1056/NEJMp1314965

PRESENTATION SLIDES: SRPC Rural & Remote Medicine Course: Less is More Medicine

The  handout  for my talk.

The handout for my talk.

The slides from my Society of Rural Physicians of Canada (SRPC) Rural & Remote talk are now available on Prezi.

The handout can be seen here.

Please explore this website to find out more. Read about other projects, attend a conference or event, or try out a shared decision making tool.

I would value any feedback via Twitter (@LessIsMoreMed) or via email, whether about the talk (if you attended) or about this website or topic in general.

This conference had a great number of speakers on subjects related to mine, ranging from Wendy Levinson on Choosing Wisely to Dee Mangin's keynote and workshop about tackling polypharmacy, to some of the hard-hitting EBM stuff from Ken Milne of the BEEMGroup and Mike Allan/Mike Kolber of Tools for Practice. On Saturday we'll hear about antibiotic overuse from Keith White in his session "Put the pen down and back away."

Inappropriate health care (or "too much & too little medicine") is a prevalent issue; it's great to see it being tackled from so many different angles.

To find out more about my past and future talks, look at the Media/Talks section.

Source: https://prezi.com/fypbc5slxilc/srpc-rural-...

The Upshot reflects: Patients overestimate benefit and underestimate harm of tests & treatments

In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.

Their Conclusions and Relevance section explains the take-away it nicely:

The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.

This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.

For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer. 

94% of patients overestimated the benefits of bowel cancer screening.

Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:

Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.

 These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.

Source: http://www.nytimes.com/2015/03/03/upshot/i...

Better informed women probably less likely to choose mammography

Screen Shot 2015-02-19 at 8.53.24 PM.png

An interesting article was published in the latest Lancet: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial.

In brief, women who got information about the risk and possible harms of breast cancer screening (by mammography) were less likely to intend to be screened. The study didn't go on to look at what the women actually chose (only what they intended to choose). However, it still confidently suggests that women who have all of the information are less likely to get screened.

Contrast this informed approach with the classic approach from the well-intentioned doctor: "You need a mammogram to screen for breast cancer. Here is the requisition."

It is not wrong to say no. (These are the words of Dr Iona Heath - well ahead of the curve - in the title of a  BMJ paper in 2009 regarding this same topic).

It is not wrong to say no. And the more you know, the more likely you'll say no. 
 

Not sure what to do for yourself?
Not sure how to start discussing this with patients?
 

- Here is a Canadian resource to help you decide if Mammography is right for you; it's not perfect but it is a start

- Below is an icon array from the Harding Center for Risk Literacy that helps visually represent the benefits vs. harms of mammography:


Source: http://www.thelancet.com/journals/lancet/a...