Less is more, InVivo Magazine

in Vivo Magazine

in Vivo Magazine

In the spring, I had the pleasure of being one of many people interviewed by Julie Zaugg for In Vivo Magazine.

Their sixth issue featured Less is More with data and opinions from mainly Swiss physicians and researchers. 

From the by-line, it seems they've missed the idea entirely

People are beginning to speak out against over-medialization. Measures are being taken to encourage less care, even if that means giving up old certainties.

That sounds like doing less is a terrible idea! Fortunately, the article comprehensively features the benefits of taking this approach to care. Comfort with uncertainty is one trait that can make a good physician great. That piece explores the state of the 'overmedicalised world,' the causes for it, and what some of the remedies might be. My emphasis? Patient-centred care.

You can see the article here, or explore the whole issue on Issu. If you'd like to see other interviews, articles, or talks I have participated in, check out the Media section.

 

It was wonderful to be a small part of the article and because of my involvement, I learned about "Smarter Medicine," a Swiss campaign [in German and French] similar to Choosing Wisely;  I have a feeling that they two will be integrated in time. This and other projects around the world are featured on the ever-growing Projects page.

 

 

Source: http://www.invivomagazine.com/en/focus/chr...

"#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

Atul Gawande: why the health care system should stop trying to help everyone live longer

Quality matters. It's not just quantity that counts towards the end of our lives, and in fact, most people would choose "good time" over "any time." Physicians know this but for many reasons we can't always help patients have the best life possible before death.

Dr. Atul Gawande recently did an interview with the Washington Post on the subject, and it felt authentic. While admire his work, I do not consider myself an unconditional devotee. However, this article is truly amazing.

It is a call to action. He graciously and decisively invalidates all the excuses that physicians create to not tackle end-of-life discussions with patients, confessing some of the challenges along the way.

Read more in The Washington Post.

Some of my favourite excerpts are here:

HP: One tough question. I watched your lecture today with some primary care physicians. Their reaction was to say, “Of course all this information about the need for conversation in end-of-life care was revelatory to you, Dr. Gawande. You’re a surgeon.” In your telling of the story, how much did the culture of specialty care fail to prepare you adequately for the challenges recounted in your book?

AG: Look I’m a surgeon--highly procedural, geared towards always being able to offer something more. It’s no surprise that this field did have prepared us formally for these kinds of conversations. Furthermore, I’m in an academic medical center, high-end Mecca. Many people come there because they want that experimental therapy, the last ditch maneuver against all odds.

. . . If these [end of life] conversations are so important--and people across other fields seem to know it--we’re still not having them. It’s not happening for two-thirds of people with advanced cancers for example. We have evidence that these conversations are even less likely to happen for other common things people die of: congestive heart failure, for example.

Maybe that’s because families and patients tend to move on to a specialist rather than the primary care doctor for these conversations, but I often find primary care doctors aren’t having them, either.
HP: Even if they had the skill to have the conversation, that’s not really who the patients are looking to for these conversations.

AG: If you look at the studies, they find that having a palliative care doctor or geriatrician more closely involved in care can lead people to forego aggressive therapy sooner and have better outcomes--not only less suffering but even improved survival. But we don’t have enough of these doctors to go around. Furthermore, there’s something wrong with the idea that you outsource this kind of decision-making and discussion.
HP: One of your book’s saddest quotes comes from a hospice patient, who says: “The oncologist and the heart doctor told me that there’s nothing more they can do for me.” It’s as if palliative care and hospice are the consolation prizes we give you when we really can’t do anything more.

AG: . . .
Even when we are needing to handoff, I’m involving someone who is going to have palliative care or hospice or primary care team. I’m not involving them because there’s nothing more I can do. I’m involving them because we require other people’s expertise to help us achieve what we’re trying to do.
Source: http://www.washingtonpost.com/blogs/wonkbl...

CMAJ Interview: Choosing Wisely Campaign Well Received

I had the great opportunity to be interviewed about the Choosing Wisely Canada campaign this week by CMAJ writer, Wendy Glauser: Choosing Wisely Campaign Well Received.

It was a positive experience, and it looks like I need some interview practice! For the record, I'm very excited about the Choosing Wisely Canada release and about the fact that this is coming from the Canadian Medical Association (CMA). The CMA works very hard at health advocacy on a national level, and I think this is an exciting campaign because it reaches patients as well as healthcare providers.

I think Dr. Nancy Morden makes an important point  - a lot of the Choosing Wisely information has been around for a long time. The gap is in the adoption of it, and I am optimistic that because of the reach of this national campaign, we'll see more physician uptake, and we'll see more patients educating themselves and bringing questions about "do I really need this test or treatment" to their doctor, NP, pharmacist, etc..

Ms Glauser and I had a long conversation about how the recommendations are an excellent start, a small part of a broader cultural shift, and how I am delighted with the Family Practice and particularly Geriatrics recommendations as I use some of these daily in my work as a hospitalist. I also tried to emphasize that the recommendations create great points of discussion with patients, nurses, and allied health staff. I think the key to this campaign is in starting really great, patient-centrered discussions, and 'thinking twice' about the tests and treatments that may be undertaken.

As far as the nursing point I spoke of, I tried to indicate that the practice of overuse of benzodiazepines and antipscyhotic sedatives is an area that we are constantly working on.

We all know that nurse to patient ratios have become unfortunately extremely challenging for good care. The nurses are more than qualified to assess and treat their patients expertly, however, if a nurse has 8 patients and half of them are confused, it becomes a real challenge to keep close tabs and achieve safety for each. When all is done to prevent confusion or delirium, there are still patients who will - because of underlying illness - become agitated or aggressive, to the point of potential safety issues such as harming themselves, other patients, or caregivers, interventions of some kind are required.

We often receive calls about delirious patients at night, and sometimes these requests are specifically for sedative medication. The first treatment is to use environmental means, reorientation, and to correct the underlying medical cause for the acute state of confusion. However, it's not uncommon to have requests for medication, and physicians - and now the Choosing Wisely campaign - are responsible for educating nurses as well as patients about the risks of these medications. Personally, I respond to almost all phone calls requesting benzodiazepines for elderly patients with a discussion of alternatives, why benzodiazepines are likely contraindicated, and together with the nurse, develop a different approach. For antipsychotics, I tend to emphasize the cardiovascular risk, avoid where possible, and if needed, use the lowest dose available writing "use PRN (as needed) sparingly for aggression and agitation." Nurses respond very well to these discussions and often help by offering other creative solutions for helping manage patient behavior without medications.

With these as with all treatments, we need to think carefully about the other options, the benefits and harms, and use them only in the right contexts, with frequent re-evaluation.

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Of course economics is a factor in Canadian Health Care. I believe that good care has to come first, and if economic benefits follow, that would be a fortunate result. Perhaps with any savings from our new found focus on ordering appropriate tests and treatments, we can invest more in areas of our system where patients are marginalized, under-supported, and under-cared for.

Physicians and patients will be driven to follow the recommendations and spirit of Choosing Wisely because it is the right thing to do, to empower patients to achieve their health care goals and to minimize the harms of unnecessary interventions along the way. (I wish that had made it into the article!)

I want to support the Choosing Wisely recommendations wholeheartedly as just that - they are not "rules" - but rather recommended points for reflection and dialog. The key is that we must carefully consider each thing we do, and the majority of the time, our practice will fall under these very clear suggestions from our National specialist bodies. Fortunately, Dr. Rick Glazier seems to have made this point clear; there are always exceptions to recommendations, and guidelines are to guide us intelligently, not to restrict practice unilaterally or to get in the way of 'good medicine.'

These suggestions of this Campaign will stimulate worthwhile and illuminating conversations with patients and ultimately, care must be tailored to the context, needs, and goals of our patients. That's how Choosing Wisely Canada will help guide excellent care for Canadians.