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/