Taking Action on Overuse: A Framework for Change (for Health Orgs & Institutes)

It has been a while since I discovered any new organizations doing work on the topic of overdiagnosis and the related issues of overtesting and overtreating. Many different projects and initiatives explore the subject; some, like Choosing Wisely, make lists of 'do not do' recommendations. Others, like Minimally Disruptive Medicine provide thoughtful reflection and model practices to show us how to burden our patients less and engage them more. The Lown Institute and their Right Care Alliance work at many levels, be it in political advocacy, cultural change, or clinical education. 

The Right Care Alliance is sponsored by the Robert Wood Johnson Foundation, something it has in common with Taking Action on Overuse.  While the former is more directed at patients, clinicians, and policy-makers, Taking Action on Overuse is a group that seems devoted to supporting health organizations and institutions. Organizations interested in creating changes to provide fewer unnecessary or harmful tests, treatments, and procedures, can employ the tools Taking Action has created. 

In their words, "Taking Action on Overuse is an evolving framework for health care organizations to engage their care teams in reducing low-value, unnecessary care and make those efforts last. It identifies evidence-based strategies for obtaining buy-in, motivating behavior changes, and providing the necessary support and infrastructure for health care providers to engage and lead their peers in making the changes that improve the value of health care."

Their Assessment can help you figure out whether your institution is ready with best practices, and gently guide you there. Likewise, their Framework can help you create the right conditions for change in a climate where many still believe "more is always better."

Check out their website here to learn more.

Source: https://takingactiononoveruse.org/

Making change: The Right Care Movement

If you are reading this, you already know there is an epidemic of overuse in health care. Yes, there is underuse too, and this has been the subject of many lobbying and quality improvement initiatives to date. The medical-industrial complex, particularly in the United States, has capitalized on the fears of individuals who worry they might be victims of underuse, to the tune of billions in unnecessary and harmful "just to be sure" testing, medications, and procedures.

Of course the health of individuals and populations is primary, but we cannot discuss this in isolation, without due attention to cost and sustainability. Given the finite resources we have in health care, we can't afford to throw away the precious time of patients and clinicians, or the money of patients and taxpayers. The best way to fix either problem is to see them – under- and over-use – as one. We need the right amount of care.

Who doesn't dream of a problem in which all you have to do is shuffle the deck to solve it!? This resonates strongly with my predisposition (and tiny amount of training) with Integrative Thinking.

The classic example of two sisters splitting an orange is a good illustration of the potential of integrative bargaining, as well as its elusiveness (Follett, 1940). Two sisters both want an orange, and they compromise by cutting the orange in half. What they would have discovered had they discussed it, however, is that one sister wanted the pulp for juice, and the other wanted the peel for a cake. Discovering that they each wanted different aspects of the orange would have helped the sisters to split the orange in a way that each gets the most individual utility out of the agreement
– Kirk D, Oettingen G. Gollwitzer, PM. (2011). Mental contrasting promotes integrative bargaining. International Journal of Conflict Management, 22(4), 324-341.

This is not a traditional way of thinking. The idea that "less" can lead to "more" is not intuitive. Some examples may help to illustrate the meaning of this when applied to health:

1.By ordering fewer unneeded tests and consultations for one patient (say, to review their cardiovascular profile), the clinician can instead emphasize and support the role of lifestyle changes and free up the patient's time and energy to exercise (which will improve their health far more than any cholesterol test or drug could).

2. If a patient can stop paying for a medication she doesn't need, she has a better chance of making rent payments that month, decreasing stress and the morbidity associated with homelessness as well as reducing the chance of an adverse event or side effect from medication.

3. If one patient's MRI for a sore knee is cancelled because it was planned to assess for a meniscus tear and is not needed as meniscus surgery is not shown to be effective, then timely access is now an option for another patient who needs that MRI (perhaps they've clinically had a stroke and the CT was normal, so the pattern of pathology on the brain MRI would change the treatment plan to prevent further strokes)

It goes on. However, because many people don't think about the big picture for themselves, their practice, or society as a whole, it can be hard to convince them to consider the 'Less is More' mentality. They may only hear "less" and run screaming.

This is why we need to create a huge swell of support, a cultural shift to make the discussion about overuse and underuse the norm. Jeanne Lenzer explains more about how the Lown Institute is attempting this with the Right Care Alliance in The Backstory—Is US healthcare a frontier for a new civil rights movement?

Source: http://blogs.bmj.com/bmj/2016/05/13/jeanne...

Quality Forum: Choosing Wisely by Jessica Otte on Prezi

10 minutes: That's how much time I had to tell the audience at the BC Quality Forum about the Choosing Wisely Canada campaign.

10 minutes may be the schedule duration of a routine patient visit with their GP. That's a short amount of time! In this short time it is hard to have a fulsome discussion with a patient about their condition, review their history, check in with their goals, and plan a strategy of treatment. It's even harder when the patient has 3 things they want to discuss!

10 minutes is not enough time to change the world - unless you do it a little bit at a time! That's why the take-away from my talk was simple:

If you feel you may need more, check out the slides on Prezi.

If you want to see other talks or articles I've done, go to the Media/Talks section.

Source: https://prezi.com/z0wgdfkmh64p/quality-for...

Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals | National Post

In our disposable culture, it is unsurprising that the bleed of this trend into healthcare has gone largely unchecked.

Operating rooms now use scads of throwaway equipment, saving sterilizing time and shaving off some intra-operative minutes by using devices that are slightly more specialized for components of the procedure.

Surgeons, nurses, and patients are all unaware of the cost. In fact, "Surgical residents and staff have a generally poor knowledge of the cost of common consumable products used in the operating room," according to a recent study in Laryngoscope by Canadian otolaryngologists.

Tom Blackwell of the National Post highlighted the issue and discovered some of the simple changes that administrators and surgeons could make to save costs without significantly impacting operation times. These efforts would also reduce landfill waste, something not emphasized in the article, but a very important consideration for the long term sustainability of our health care system.

See the video and article: Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals.

Source: http://news.nationalpost.com/news/canada/s...

CHANGE Alberta: Reversing Metabolic Syndrome with Exercise and Diet

The whole point of a "Less is More" approach to Medicine is to focus on things that really help people live well. If we take resources from unnecessary tests and treatments, we could instead invest in social determinants of health, preventative health, and the tests and treatments that actually make a difference to the quality (and quantity) of people's lives.

It's no secret that an active lifestyle and a reasonable diet correlate with better physical and mental health. While unfortunately the studies have not been yet done to show that exercise prevents cardiovascular events in people with increased cardiovascular risk, we do know that generally, people who exercise can gain up to 4.5 years of life compared with sedentary counterparts. However, it is very hard for family doctors, and even NPs who may have a bit more time with each patient, to help patients alter their eating and exercise habits in a meaningful and lasting way.

Enter CHANGE Alberta. The Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) Alberta project seeks to find a way to reverse metabolic syndrome by supporting patients with nutrition and activity plans. Explore the website to learn more about the team-based approach, involving dieticians and kinesiologists, that they employed in primary health care settings.

I met Dr. Doug Klein (@DrDougKlein) at the Family Medicine Forum in Quebec in November, where he was sharing their promising results; with 302 patients enrolled, at one year, 28% had reversal of Metabolic Syndrome and overall 52.4% had reversal of at least one feature of Metabolic Syndrome.

Is this something you could integrate into your primary health clinic?

Transforming the Canadian Healthcare System with Integrative Thinking

I had the incredible privilege of participating in the inaugural class of a partnership between the Canadian Medical Association (CMA), the Provincial and Territorial Medical Associations (PTMAs), and the Rotman School of Management (University of Toronto).

Forty physician leaders from across the country are spending a week together, learning about Integrative Thinking and its application to Transforming the Canadian Health Care System.

My experience:

- 1 week in a room with 40 flabbergastingly amazing physician leaders from across the country
- Values: we all want to achieve the same things for patients, have similar values, and all have different ways to do it; some have tried and failed, some have succeeded, others are not sure where to start
- Focus: on how to radically transform health care in Canada using Integrative Thinking
- Experts: Rotman School of Management geniuses, the earnest and persuasive Brian Golden & the engaging and hilarious Jennifer Riel, as well as conflict superstar Janice Stein (who I remember watching on TVO as a teenager). Also "Outside Voices" representing PTMA leadership/government, with a call to action from a peer leader.
- Background: the history of the technique of Integrated Thinking is nebulous, but in interviews, Roger Martin identified it as the common strategy used by many successful leaders use to work through impossible or "wicked" problems. It may be rooted in elements of Hegelian dialectic and is highlighted in F. Scott Fitzgerald's writing:

The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see things as hopeless and yet be determined to make them otherwise.
— F. Scott Fitzgerald

- Technique: cracking the unsolvable problem by changing the rules, addressing assumptions, and employing the tension between two opposing models to create a third, better answer. And there are many of these better answers, never just one.

The Rotman School of Management defines integrative thinking as:

"the ability to constructively face the tensions of opposing models, and instead of choosing one at the expense of the other, generating a creative resolution of the tension in the form of a new model that contains elements of the individual models, but is superior to each . . .

Integrative thinkers build models rather than choose between them . . .  they creatively resolve tensions without making costly trade-offs, turning challenges into opportunities."

- Variations:

  1. weaving best elements of conflicting solutions together to make a better hybrid (HIDDEN GEM)
  2.  stretching or bending one model in a way that it can produce the best aspects of the opposing model (DOUBLE DOWN)
  3. re-framing the problem, taking smaller elements of it or changing the underlying problem (DECOMPOSITION)

- Examples: Double down integration

Wal-Mart Stores Inc. is an example, when the company thought it had to choose between protecting the environment or protecting the bottom line. Under attack from sustainability critics, the retailer doubled down, using its strong influence on its supply chain to push suppliers into greater sustainability without raising its overall costs.

Read more in this handy summary, "Melding two thoughts to find the best approach," in the Globe and Mail; the original article is "Integrative Thinking in Three Ways." I could not find a free version but if you have a subscription you can read it in the Harvard Business Review.


- Our Example: Our group had to design an acute care system that could get the best of patient empowerment and physician accountability. We designed an emergency room flow that had various points at which self-directed patients could enter or exit the system, with an advocate or medical expert able to guide them at each step along the way.

We could have easily suggested Shared Decision Making where providers and patients work together to make decisions at every step (Variation 1), a totally patient-responsible system that somehow managed to uphold and employ physician guidance & expertise (Variation 2), or suggested that patient-directed care would be in some settings and paternalistic (provider-dictated) care would apply in others (eg. in an emergency, where the patient cannot be consulted) (Variation 3, kind of).
Frankly our rough solution seemed to involve elements of each approach. As a group member said, "we gave the patient a paddle instead of sending them down the creek (of acute care) without one."

Other considerations in the process:
- reconsider 'opponents' in negotiation as partners in creative problem solving; you probably share common goals (eg. both government and physicians want good quality healthcare for patients); working with those in mind will help create a win for everyone
- slow down, take a step back, and think about the needs you are addressing and challenge all assumptions before jumping to a solution
- know the people that you are representing and frequently share with them and seek their input
- create an institutional culture where conflicting ideas are embraced and used to make the projects and product better; encourage this with techniques like a rotating Devil's Advocate, focusing on common goals and values, and not forgetting about the psychology of political intelligence (which we learned through watching 12 Angry Men)

How does this relate to Less is More?

I assure you, it relates entirely! Furthermore, learning about Integrative thinking has allowed me to take a step back and look at the underlying needs, tensions, and to work through to some solutions. Plus, I need to round up some opposing viewpoints, because people who challenge the idea are my new best friends (for creating change)!

Stay tuned for the next post.

Less is More: The Beginning, Time to Blog

Now that the Less is More Medicine website is live, and everything's atwitter, I can start tackling the 180+ articles I have saved up on the subject, providing a précis and posting them here. The first priority was to complete and share the website, but the real utility of the site will be in highlighting all the incredible work that is already underway. Every day there are newspaper articles, scholarly journals, and blog posts published about the idea of Less is More or Appropriateness or Choosing Wisely.

Whatever you call it, patients, families, doctors, nurses, technicians, policy makers, and governments are starting to take note.

It's a pretty exciting time and with all this momentum, the task of changing the culture of medicine does not seem so impossible.

One step to move forward toward 'the right amount of care' is engaging physicians to lead their peers, by example and education. Another is enabling patients to have a voice, be it by way of shared decision making, political advocacy, or some other means.

I don't have all the answers. I am hoping that by practicing appropriate care, being part of the discussion, publicizing the issues, and beginning to talk in medical school classrooms or at conferences, I will help add the the momentum.