Choosing Wisely Canada Talks

Earlier this month, I participated in a Choosing Wisely Canada Talks webinar. Drs Kimberly Wintemute and Anthony Train shared insights around a clinician's professional obligations and led a discussion around practical tips for having conversations with patients in these scenarios. You can see their talk and others in the Choosing Wisely Canada Talks series online.

This primary care discussion was incredibly relevant, and we covered a few tough topics including:

  1. A healthy patient requesting non-indicated screening blood work
  2. A patient requesting unnecessary imaging eg. MRI for lower back pain
  3. When a naturopath has told patient to ask MD to order a series of blood work
  4. A patient with a viral infection insisting on antibiotics
  5. Chronic use of sedatives/hypnotics including benzodiazepines in an older patient

It was great to have a mixture of people, including a patient voice, in the webinar. Some of the themes that emerged were around building a trusting relationship, exploring the patient's fears or goals and addressing those, having a discussion about risks vs benefits, using analogies/humour to convey a message, and using physical exam and other techniques to reassure patients.


"Choosing Wisely Talks take place on the 1st Thursday of every month from 12pm-1pm ET. Each workshop is led by an inspiring guest speaker, usually someone who has made significant gains in implementing the Choosing Wisely recommendations. Through a webinar format, participants tune-in to a live presentation by the guest speaker, followed by an interactive Q&A discussion. Participants usually leave each workshop with:

  • A greater appreciation for the impact of overuse
  • Ideas and inspiration for their own Choosing Wisely implementation project
  • A better grasp on potential barriers and opportunities to successful implementation"

 

Go to the website and use the right-hand menu to add these valuable events to your calendar or sign up for the newsletter. The next session is November 3rd from 12-1PM Eastern Time.

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.

 

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...

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

Transforming Primary Care: Rx | The Quiet Revolution (DOCUMENTARY)

Thanks to Dr Dave Elpern (Cell2Soul) who shared this video, a 90-min PBS documentary, Rx: The Quiet Revolution.

In this inspiring 90-minute documentary, filmmaker David Grubin – the son of a general practitioner – takes his camera across America to focus on the challenges and triumphs in our country’s health care delivery system. The four segments that comprise Rx: The Quiet Revolution introduce us to a diverse group of doctors, nurses, and health care professionals who are transforming the way we receive our medical care: lowering costs by placing the patient at the center of their practice

Certainly the vignettes of Dr. Loxterkamp remind me of Vancouver's Home ViVE program and the kind of doctoring I aspire to. Likewise, the Nuka approach is something that could work beautifully for Nunavut, if and when the people are ready.

The film highlights four programs that are revolutionizing the way health care is delivered. What they all have in common is a patient-centred approach, remembering that people and relationships are at the heart of health:

 

- On Lok Lifeways Program for All-inclusive Care of the Elderly (PACE) program: "On Lok’s goal is to allow frail and elderly seniors with chronic illnesses or disabilities — who would normally require nursing home care — to live with dignity in their own home"

- The Seaport Community Health Center, where Dr Loxterkamp is re-inventing the patient's medical home: "Some of our patients miss the 'old-fashioned country doctor,' the one they could call whenever they needed to be seen– before the computer, before a team of assistants separated them from their doctor, and when they mattered more than their disease."

- Alaska's Southcentral Foundation which developed the Nuka System of Care: "This is a name given to the whole health care system created, managed, and owned by Alaska Native people to achieve physical, mental, emotional and spiritual wellness. Nuka is an Alaska Native word used for strong, giant structures and living things. The relationship-based Nuka System of Care is comprised of organizational strategies and processes; medical, behavioral, dental and traditional practices; and supporting infrastructure that work together - in relationship - to support wellness."

-  The Center for Telehealth at the University of Mississippi Medical Center: Their Diabetes Telehealth Network aims to "provide people with diabetes more consistent and timely access to clinicians through the use of telehealth technology in their homes"

 

The documentary can be seen online in its entirety here.

Source: http://rxfilm.org/

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-...

Update: POEMs help identify clinical practices for the Choosing Wisely Campaign

Update: Grad et al's paper is now published! View the full text: Patient-Oriented Evidence that Matters (POEMs) Suggest Potential Clinical Topics for the Choosing WiselyCampaign in JABFM.

[this blog post below was originally published Nov 24, 2014]


It can be challenging to cultivate topics for the Choosing Wisely Campaign; Montréal family physician and researcher Dr. Roland Grad (bio) and his group have found a unique way to harness an existing tool to do so easily.

Dr Grad presented a poster at the Family Medicine Forum (FMF) indicating one way forward could employ physician ratings of Patient-Oriented Evidence that Matters (POEMs).

POEMs are short summaries of relevant and valid information for clinicians. These are free for Canadian Medical Association (CMA) members (login to cma.ca, click on your name, and go to the Manage Newsletters section) and are basically quick reads with commentary on recent clinical trials, systematic reviews, etc. [Non-CMA members can go to Essential Evidence Plus]

Grad, Pluye, Shulha and Tang focused on one item on the validated questionnaire used by physicians to evaluate POEMs, which asked whether the POEM helped the practitioner in ‘avoiding an unnecessary diagnostic test or treatment’.

They identified the top 20 POEMs in each of two years most commonly associated with helping avoid unnecessary tests or treatment. Interestingly, only 11 of the 40 POEMs had a corresponding item on the Choosing Wisely master list.

[short version: there's a huge collection of already identified practice-changing recommendations just ripe for the adding to a campaign like Choosing Wisely!]

Their process provides an easy way to gather possible topics for future Choosing Wisely lists and could aid in the expert panel approach.

The group's paper is now in the Journal of the American Board of Family Medicine.

Perspective: Want to learn the value of healthcare? Try to diagnose your own mother

Dr Ranjana Srivastava is a specialist. Specifically, she is an oncologist (cancer doctor).

Naturally, she thought the worst when her mother became ill and started thinking up a series of diagnoses, implications, tests, and treatments. She struggled a little to decide how much would be important and good advocacy for her mom, and how much was "too much" and might do more harm than good.

Her husband, a GP, interrupted and helped Dr. Srivastava's mother decide what to do next - and in doing so, also answered Dr. Srivastava's bigger question:

Why is it so hard to see the value of experienced GPs?

Read the full article in the Guardian to understand her answer.

Source: http://www.theguardian.com/commentisfree/2...

PRESENTATION SLIDES: Choosing Wisely (& Beyond): Starting Conversations Around Unnecessary Tests and Procedures

The slides from my UBC CPD 50th Annual Post Graduate Review in Family Medicine talk are now available, here on Prezi.

The handout can be seen here.

Start with the 11 recommendations for family practice physicians/patients from Choosing Wisely Canada, and then 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.


It was a pleasure to share this brief presentation, to hear the great questions and discussions on the subject, and to see how these challenges were highlighted in the other talks of the day. Inappropriate health care (or "too much & too little medicine") is a prevalent issue. Hopefully starting with campaigns like Choosing Wisely and the effort to curate similar projects/conferences/resources with "Less is More in Medicine" provides a good start to tackling this immense issue.

20 minutes is not a long time to explain the problem of "too much medicine," to share what is already being done and to inspire and create a call to action. Fortunately, I have the opportunity to speak at other events including the SRPC's Rural and Remote conference in April in Montreal as well as at the St Paul's Family Medicine course this November in Vancouver.

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

Source: https://prezi.com/bpguaxve_yyx/ubc-cpd-50t...

REGISTER: 50th Annual Post Grad. Review in Family Medicine (Vancouver)

Interested in updating your core family practice knowledge?

Want to hear about the Choosing Wisely campaign, or some 'next steps' if you're already an expert? 

I'll be speaking at The University of British Columbia (UBC) Continuing Professional Development (CPD) 50th Annual Post-Graduate review in Family Medicine. I was asked to speak about the Choosing Wisely Canada Campaign and it's an exciting opportunity to share my passion for this and other initiatives within the movement towards appropriateness in care.

As some of the audience may already be familiar with the campaign and using it regularly, I will also offer some "next steps" ideas for these keeners.

My talk, "Choosing Wisely (& Beyond): Starting Conversations Around Unnecessary Tests and Procedures " is at 11:05 on Tuesday, February 25th. To see slides/handouts from my previous talks or to see scheduled upcoming talks, go to the MEDIA/TALKS section of the site.

The Post Graduate Review is a pretty high-yield, practical sort of CME event and knowing some of this year's speakers, I can say I'm really looking forward to talks on Palliative Care, Interesting Cases in Rheumatology, Counselling Anti-Vaccine Parents, Weight Loss in Obesity, and many more! [Sadly I'll miss some of them as my partner's vacation starts on the 26th and we'll be off adventuring, but when it comes to vacation, more is more ;) ]

 

Hope to see you there! (See the brochure and registration form or register online)