Choosing Wisely Canada: 3rd Wave of Reccomendations

Choosing Wisely Canada has released their 3rd wave of recommendations!

Groups like the Canadian Association of Emergency Physicians (CAEP), Canadian Society of Hospital Medicine (CSHM), three psychiatry groups (Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association) and three surgical groups (Canadian Spine Society, Canadian Society for Vascular Surgery) have all developed lists of the top things that patients and doctors should question. The Canadian Society for Transfusion Medicine also added 5 new recommendations. See the new recommendations here.

This round was particularly interesting for me as I got to witness the process of the development of the CSHM list and participate in some stages, though not extensively. It's a tough task, whittling down all the ideas to find well-evidenced items that represent key areas for improvement, and try to avoid duplication of other specialty society recommendations. The group has to consider that many things which are good ideas and really really important to tackle, may not be suitable as the evidence behind them may be vague.

For example, though we all felt that discussing 'goals of care' or advance directives and resuscitation statuses (eg. DNR) with patients is very important, there's little data about why/how/when this should happen and what impact it actually has on patient well-being. Should it be discussed by the hospitalist? The GP? On all admissions? Only when a patient's status changes?

Ultimately it was impossible to make a firm statement that was robustly rooted in evidence, though our 'gut' feeling was strongly that we need to be having these discussions and that patients and doctors both should be starting conversations on the subject.

Choosing Wisely, as ever, forms a great starting place for discussing overuse of harmful and unnecessary tests and treatments. Yes, some of the recommendations are 'low-hanging fruit' but we have to start somewhere, and Choosing Wisely is great at getting us started talking about the facts that "more is not always better" in medicine.


Choosing Wisely Canada extra resources

Being part of the Early Adopters collaborative for Choosing Wisely Canada, I've been made aware of some really useful resources that you may not have heard of yet.

Thanks to Tai Huynh (Campaign Manager) and Karen McDonald (Project Manager) with Choosing Wisely Canada for allowing me to share their commentary and these great links:

1.     Canadianized patient pamphlets

In collaboration with Consumer Reports Health and Canadian medical specialty societies participating in Choosing Wisely Canada, we have (to date) released 25 lay language patient pamphlets to help educate patients and facilitate provider-patient conversation on tests, treatments and procedures that may not be necessary. These pamphlets can be found in the materials section of the Choosing Wisely Canada website  and are downloadable as PDFs. The generic patient pamphlet contains four questions patients are encouraged to ask their doctors.

 2.     Instructional videos to help providers and patients think and talk about overuse

The ABIM Foundation funded the Drexel University College of Medicine to develop a set of interactive instructional modules to enhance physician and patient communication around the specialty society recommendations from the Choosing Wisely campaign. Developed in collaboration with nine medical specialty societies, these modules are designed to help physicians, patients and other health care stakeholders think and talk about overuse of health care resources by providing strategies for physicians to build trust and address patient attitudes and beliefs that more care is not always better care.

These videos can be accessed from the US Choosing Wisely website, modules section. They are a bit tricky to locate, so here are some examples: 

3.     Washington State Choosing Wisely Task Force toolkit

A PDF of the Washington State toolkit created for physicians or other health care leaders struggling with how to integrate Choosing Wisely’s evidence based best practices into their practices or organizations.

4.     Spreadsheet of Canadian physician recommendations

A spreadsheet containing all 102 CWC recommendations released to date is attached and can be downloaded from our website


Should Patients have their own Choosing Wisely list?

I'm possibly Choosing Wisely's most keen fan. Both the American and Canadian campaigns have helped to kick-start the process of shared decision-making between patients and healthcare providers, particularly in the contexts of overdiagnosis and overtreatment.

Some have criticized the campaigns as going after "low-hanging fruit," i.e. targeting the interventions that are not at all controversial, the ones where most doctors have been for years following the Choosing Wisely recommendations. I don't disagree; I'm pleased to say I've been trying to do a lot of the Geriatric and Family Practice suggestions since I started practice. But going after the easy stuff is not a bad idea. We need to start somewhere, and Choosing Wisely's recommendation lists represent the first of many steps towards providing the Right Care. The campaign is about starting a dialogue between patients and providers, making explicit the need to discuss the balance of harms and benefits of particular tests and treatments.

My view is that the broader message, driving campaigns like Choosing Wisely, is about creating a partnership wherein patients are empowered to be responsible for their own health. Patients can ask questions and caregivers can provide expertise and recommendations. Just as a patient has expectations of their physiotherapist or nurse practitioner or specialist, healthcare providers have expectations of their patients too. Everyone involved wants common sense to be applied to the healthcare that's being delivered. There are certain things only doctors can do (ordering the right test, calling a specialist for help) and certain things only patients can do (taking medications as prescribed, exercising regularly). We can help each other out by talking about these things, but we can't actually act for the other person in the equation.

Chatting recently about the campaign to a colleague, and thinking about my own status as a patient, I began to wonder why patient advocacy groups have not yet created their own "Don't" lists. True, patient groups have been involved in the development of Physician Recommendations, however I think it's a bit of a missed opportunity: why not provide patients room for a list of their own?

I think patients are capable of clearly delineating some things that they can do (or not do!) to be healthier and to stimulate discussion with their physicians.

Here are some of my suggestions. Are they way off base? Do you have some of your own? Comment below!

Patient Top 5 Recommendations:

1. Don’t under-value the importance of a healthy lifestyle: avoid smoking, maintain a healthy weight, and exercise regularly. Ask for help if you are having trouble with these things.

2. Don’t wait to seek help for emotional and mental health concerns.

3. Don’t forget to write an Advance Directive and discuss your wishes with your family so they'll know how to best respect them when you are ill or dying.

4. Don’t undertake any test or procedure unless you feel that you understand the potential benefits and harms adequately; remember that you can always refuse.

5. Don’t expect someone else to take ownership for your health but do expect partnership from health providers in helping you achieve your goals.