New Choosing Wisely toolkit with patient handouts - Family Medicine, CFPC

The College of Family Physicians of Canada (CFPC) and its Patient Education Committee (PEC) are pleased to release a new Choosing Wisely Canada™ (CWC) toolkit. This innovative initiative is aimed at educating the public about anticipated changes in how family physicians approach health care prevention.  

Building on the success of the CWC campaign, the CFPC launched a whiteboard video titled Do More Screening Tests Lead to Better Health? This video was developed by the Dr. Mike Evans Lab group and focuses on a number of common screening tests: vitamin D malabsorption, mammography, thyroid testing, chest X-ray and electrocardiograms, Pap smears, dual-energy X-ray absorptiometry (DEXA), and annual physical exams.

The new CWC toolkit provides the following resources: 

Please see www.cfpc.ca/ChoosingWisely for more information, and if you want to see patient handouts and shared decision-making tools from other sources, check out the Less is More Hands On Tools page.

 

The Preventative Visit and Choosing Wisely

The preventive health visit is not synonymous with an 'annual physical'

I always felt lost when asked to do a general exam on a healthy person. Every physician performed it differently. Do we check for breast masses? Feel the thyroid? Look at the tongue and mouth for squamous cell carcinomas? Check the belly for a pulsatile mass? Listen for a murmur? Heck it would take hours to go over every mole and mucosa, to palpate every bump and move each joint. So what were we doing?

The American Choosing Wisely campaign, in the list of Society of General Internal Medicine suggestions, recommended in 2013 that physicians stop “performing routine general health checks for asymptomatic adults." (see some backing data)

Many were outraged by this, and a similar decision in Ontario by the provincial government to de-list the annual physical exam, such that physicians would no longer be paid to provide this service to patients who don't require it. The concern was mainly that very important preventative health and screening measures would no longer be undertaken.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

But, a preventative health visit is not the same thing as an annual physical. For example, we've got decent evidence that pap tests are important screening tools for cervical cancer, and have changed our guidelines to use them less frequently. And we are not suggesting dispensing with this. However, recent studies have shown that the pelvic exam (feeling the uterus and ovaries, essentially) really is not essential and many organizations are beginning to recommend against this practice. We had been doing pelvic exams out of "tradition" for the longest time - how much else is driven by tradition?

I come back time and time again to the Milstein paper from Health Affairs, Why Behavioral And Environmental Interventions Are Needed To Improve Health At Lower Cost. We know that prevention is key, but we don't know how, when, or where to deliver it. Dispensing lifestyle advice in the office probably doesn't work (eg. GP advice is ineffective in improving metabolic outcomes in high risk patients). Clearly we need something different to achieve a persuasive, meaningful impact.

A colleague recently sent me an article, from the American Journal of Preventative Medicine (access required - ePub ahead of print, Jul 2014),  which addresses concerns with the way our push for efficiency and appropriateness may be drawing attention away from the real issue of prevention. Wong, Gaster, and Dugdale write:

. . . the Choosing Wisely Campaign sends the wrong message at a time when prevention remains more important than ever, and as the data supporting it grow more complex and more nuanced. The preventive health visit has and will continue to evolve . . . The preventive health visit currently remains an effective tool for increasing adherence to evidence-based service guidelines. This is no time for us to abandon it.

I would personally need to learn a lot more about what "effective" is meant to construe in the above sentences before agreeing wholeheartedly. I don't disagree that we need to spend a lot more effort looking at prevention, but I don't think Choosing Wisely contravenes that effort. 

 

What do you think?

Testing to the Nth degree

When a healthcare provider orders a test, it may be opening the flood gates for further testing. And it's really really really hard to scramble back and undo an unnecessary test after the fact.

When a healthcare provider orders a test, it may be opening the flood gates for further testing. And it's really really really hard to scramble back and undo an unnecessary test after the fact.

Every week I save articles about overtesting, overtreatment, "right care," how to fix out health system, and so on. Today I present:

Four examples of outrageously unnecessary tests

1. An Egregious Example of Ordering Unnecessary Tests
- Patient: 21 year old healthy male for a general annual exam
- Cost: $3682.98 ($13.09 covered by his insurance), confusion, worry
- What happened: The doctor ordered a tonne of lab tests including some I've never even ordered, a stress test (unprecedented in a healthy 21 year old!), etc.
- Comment: The blog writer is appropriately flabbergasted as basically every test ordered was unnecessary; however, he doesn't take it far enough - Routine Physicals themselves are not recommended; annual exams have no scientific value.
 

2. False-Positive Results From a Diagnostic Colonoscopy
- Patient: a middle-aged man with occasional blood in stool
- Cost: unnecessary colonoscopy, exposure to risks, worry/grief about having cancer
- What happened: Although the primary care provider thought the patient had irritable bowel syndrome (IBS) and an ano-rectal source (eg. hemorrhoids) for the occasional blood in the patient's stool, a colonoscopy was ordered. It showed a polyp and the pathology was positive for lymphoma. The patient underwent extensive testing which revealed nothing. The diagnosis of lymphoma was questioned and the patient was diagnosed with hemorrhoids and IBS or food allergy.
- Comment: It's not a bad idea to tell the patient what you are thinking and why you suggest certain things:

"After this experience, the patient stated he would have agreed to an elimination diet, rectal examination, and anoscopy if he had understood what information his physicians could have obtained from these initial tests, prior to pursuing a more invasive option."


3. How the CA-125 became a $50,000 blood test
- Patient: middle-aged female given a CA-125 blood test as "screening" for ovarian cancer
- Cost: $50 000 if you include all the sequelae from that first test
- What happened: The doctor suggested being "safe" and using a test that is not meant for screening as a screening test. When the test was slightly elevated, the doctor suggested further tests. Ultrasounds, CTs, surgeries, etc.
- Comment: I can't say it better than the blog writer when he sums up the costs:

"Five months of mounting worry, loss of several organs, and a simmering distrust of doctors and their tests:  incalculable."


4. Stop hunting for zebras in Texas

- Patient: young man hit in the head with a baseball bat, may be given 2nd CT scan
- Cost: more than necessary
- What happened: A young man who was struck with a baseball bat had a CT scan that showed a Subarachnoid Hemorrhage (SAH). Dr Watson suggested he have another CT (angiogram) scan to see if a brain aneuyrsm was the cause of the bleed. Dr Jha suggested that perhaps the blow to the head was the cause of the bleed in the brain (duhhh!). Dr Watson was "hunting for zebras," i.e. looking for a rare cause to explain the problem rather than the pretty obvious, straightforward one. He thought he had to "rule out" or exclude the rare diagnosis. Dr Jha applied Occam's Razor,  suggesting that while a rare cause was possible it would be far more likely for the simple/obvious cause to be the case.

"Watson’s rationale for fishing for rarities—“can’t be ruled out”—is unfalsifiable. This phrase cannot be disproved. It smashes Bayes’ theorem and Occam’s razor to smithereens. It is kryptonite to clinical acumen . . .
. . . there is wrong: falsely declaring disease in a healthy person—a false positive. And there is (really) wrong: falsely declaring health in a diseased person—a false negative. . . [M]any doctors have chosen being wrong over being really wrong."

- Comment: To "err on the side of caution" seems best at first blush. But being careful has consequences too. In this case, extra radiation (which increases the chance of developing cancer), potential reaction to CT dye (anaphylaxis, kidney failure), the finding of things no one was looking for ("incidentalomas") and further testing required to make sure they aren't bad things, the financial and time cost of the CT scan, etc.

See the article for an excellent narration of the thought process behind this kind of decision-making.