I had the great opportunity to be interviewed about the Choosing Wisely Canada campaign this week by CMAJ writer, Wendy Glauser: Choosing Wisely Campaign Well Received.
It was a positive experience, and it looks like I need some interview practice! For the record, I'm very excited about the Choosing Wisely Canada release and about the fact that this is coming from the Canadian Medical Association (CMA). The CMA works very hard at health advocacy on a national level, and I think this is an exciting campaign because it reaches patients as well as healthcare providers.
I think Dr. Nancy Morden makes an important point - a lot of the Choosing Wisely information has been around for a long time. The gap is in the adoption of it, and I am optimistic that because of the reach of this national campaign, we'll see more physician uptake, and we'll see more patients educating themselves and bringing questions about "do I really need this test or treatment" to their doctor, NP, pharmacist, etc..
Ms Glauser and I had a long conversation about how the recommendations are an excellent start, a small part of a broader cultural shift, and how I am delighted with the Family Practice and particularly Geriatrics recommendations as I use some of these daily in my work as a hospitalist. I also tried to emphasize that the recommendations create great points of discussion with patients, nurses, and allied health staff. I think the key to this campaign is in starting really great, patient-centrered discussions, and 'thinking twice' about the tests and treatments that may be undertaken.
As far as the nursing point I spoke of, I tried to indicate that the practice of overuse of benzodiazepines and antipscyhotic sedatives is an area that we are constantly working on.
We all know that nurse to patient ratios have become unfortunately extremely challenging for good care. The nurses are more than qualified to assess and treat their patients expertly, however, if a nurse has 8 patients and half of them are confused, it becomes a real challenge to keep close tabs and achieve safety for each. When all is done to prevent confusion or delirium, there are still patients who will - because of underlying illness - become agitated or aggressive, to the point of potential safety issues such as harming themselves, other patients, or caregivers, interventions of some kind are required.
We often receive calls about delirious patients at night, and sometimes these requests are specifically for sedative medication. The first treatment is to use environmental means, reorientation, and to correct the underlying medical cause for the acute state of confusion. However, it's not uncommon to have requests for medication, and physicians - and now the Choosing Wisely campaign - are responsible for educating nurses as well as patients about the risks of these medications. Personally, I respond to almost all phone calls requesting benzodiazepines for elderly patients with a discussion of alternatives, why benzodiazepines are likely contraindicated, and together with the nurse, develop a different approach. For antipsychotics, I tend to emphasize the cardiovascular risk, avoid where possible, and if needed, use the lowest dose available writing "use PRN (as needed) sparingly for aggression and agitation." Nurses respond very well to these discussions and often help by offering other creative solutions for helping manage patient behavior without medications.
With these as with all treatments, we need to think carefully about the other options, the benefits and harms, and use them only in the right contexts, with frequent re-evaluation.
Of course economics is a factor in Canadian Health Care. I believe that good care has to come first, and if economic benefits follow, that would be a fortunate result. Perhaps with any savings from our new found focus on ordering appropriate tests and treatments, we can invest more in areas of our system where patients are marginalized, under-supported, and under-cared for.
Physicians and patients will be driven to follow the recommendations and spirit of Choosing Wisely because it is the right thing to do, to empower patients to achieve their health care goals and to minimize the harms of unnecessary interventions along the way. (I wish that had made it into the article!)
I want to support the Choosing Wisely recommendations wholeheartedly as just that - they are not "rules" - but rather recommended points for reflection and dialog. The key is that we must carefully consider each thing we do, and the majority of the time, our practice will fall under these very clear suggestions from our National specialist bodies. Fortunately, Dr. Rick Glazier seems to have made this point clear; there are always exceptions to recommendations, and guidelines are to guide us intelligently, not to restrict practice unilaterally or to get in the way of 'good medicine.'
These suggestions of this Campaign will stimulate worthwhile and illuminating conversations with patients and ultimately, care must be tailored to the context, needs, and goals of our patients. That's how Choosing Wisely Canada will help guide excellent care for Canadians.