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...

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...

"#Overdiganosis is in the eye of the beholder" The challenge begins with definition

Stacy Carter headed a great session at the Preventing Overdiagnosis 2014 conference in Oxford, which is where I met her for the first time.

 This BMJ talk Medicine interview expands on that session and on the paper written with Rogers, Heath, Degeling, Doust, and Barratt. They explore the culture (ethical and social aspects) and science behind "overdiagnosis," why it is so hard to define, and limitations of the term.

Listen at the BMJ and read the paper, which I am delighted to report, cites this website!

Source: http://www.bmj.com/content/350/bmj.h869

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.