If lobsters had doctors...

Comfort with uncertainty is an essential part of medicine, particularly in family practice and other generalist pursuits. There are many labels, lab tests, pills, and therapies, but not everything has an answer.

We must not only tolerate uncertainty, but embrace it.

Dr Rabbi Abraham Twerski, a man who marries psychiatry and spirituality, suggests that discomfort is essential for growth. This applies not just to physicians but to patients as well. Facing adversity can be the key to developing resilience. 

Source: https://www.youtube.com/watch?v=3aDXM5H-Fu...

Minimally disruptive medicine: Effective Care that Fits Workshop SEPT 2016

I read the fantastic Minimally Disruptive Medicine (MDM) Blog and want to bring your attention to the Mayo Clinic KER Unit MDM event, coming soon:

From the MDM site:

Click on the image to find out more about the Minimally Disruptive Medicine Workshop.

Minimally disruptive medicine (MDM) seeks to advance patient goals for health, health care, and life, using effective care programs designed and implemented in a manner that respects the capacity of patients and caregivers and minimizes the burden of treatment – the healthcare footprint – the care program imposes on their lives.

This site is maintained by researchers at the KER UNIT who are part of an international research team that is working on understanding and implementing MDM across the world.

Some introductions to MDM:
From the peer-reviewed press
From the medical press
From the lay press
From Wikipedia
From a presentation (video) 
From a radio interview (audio)
Complexity Care Model article

 


For more events related to "Less is More," "Choosing Wisely," "Preventing Overdiagnosis," "Shared Decision-Making," etc, go here.

CMA General Council (#cmagc): A Success for Canadian Health Care

Advocacy and policy making is just one of the levels I am working at in order to improve health care for Canadians. Sometimes there are direct links to a "Less is More" approach. The Canadian Medical Association (CMA) calls this kind of topic "appropriateness." Although the CMA's annual meeting (General Council) this year only had a few ties to this way of thinking, a few readers have asked me about the event as a whole and so I share my reflections here:

It was an incredible General Council (GC) in Halifax, NS this August. I was able to participate as a Delegate for British Columbia and I cannot explain the feeling of immense purpose and privilege involved in voting on the policy and positions of the national organization of physicians; I was elated to be a part of the formation of some incredibly socially progressive resolutions that will have a real and positive impact on the health of Canadians. We resolved to divest our organization of investments in fossil fuels, to support the principal of a universal/national pharmacare program and a basic guaranteed minimum income, to encourage informed discussions around childhood vaccination in all school age children, and to endorse harm reduction strategies like a national guideline for naloxone availability (for opiate overdoses).

There was some outcry, understandably, from those who live in areas of the country whose economies depend almost entirely on the fossil fuel industry. They were out-voted. We cheered when we made the symbolic gesture – it was not a lot of money for our organization to re-invest in other industries. It was just an incredible statement for our organization to show that the health of the planet affects the health of its people, and we are willing to take the longer view.

The general assembly agreed to disagree on the exact details of how a patient would access physician-assisted death; council continued to extend the privilege of speaking to all attendees which allowed many conscientious objectors (observers, not official delegates) to express their concerns about participation in this, now legal, act. We all trusted in the process of consultation involving government, the public, the CMA (through various other channels besides GC), and other interested bodies (regulatory colleges, insurers, etc.) and will wait to see what this more broad process concludes as far as the exact process for physicians and patients.

It was all quite cordial, actually. The conscientious objectors were respectful and registered their concerns clearly. The voice of youth was loud and clear, with many young physicians and medical students participating as non-voting ambassadors, and a few of us resident and early career physicians voting as delegates. Our push for change was LOUD! The momentum built in the room and many of us felt like serious headway was made for our patients.

As ever, we heard: “you young people are what is ruining our society.” In person the meeting was quite pleasant but those physicians following online, especially on twitter, were outraged.

Mainly, it was those who opposed universal healthcare who were ashamed of what the CMA General Council had done. Everyone voting must be “left wing radicals” and “communists.” All the young people “lack the context” to create and endorse the correct resolutions. 

But, we were there, and we did it. Yes, many of the resolutions we made and voted in may never come to fruition this year. We don’t have unlimited time and finances as an organization and to be effective we must focus on a few narrow issues. However, it is still a big win for Canadians to be able to reference this groundbreaking policy. Setting precedent and having a public record of endorsement of an organization as respected as the CMA may be just enough to help grassroots initiatives get the edge they need to grow into persuasive bringers of change.

Thinking specifically about the “less is more” approach to health care, we also passed many resolutions to help strengthen palliative care programs to make them accessible for more people, and called for regulations around genetic testing/precision medicine and telemedicine [I was a Mover]; we warned that Canada cannot blaze forward with these technologies without consideration of the considerable risks they may pose for patients.

We also recommended that our National Senior’s Strategy and the policy paper "A Prescription for Optimal Prescribing" be updated to include a specific section addressing polypharmacy, which passed on the consent agenda [I was a seconder]. See the video of my colleague, Mover Ralph Jones, speaking briefly to this motion after we knew it had passed, with what I suspect is a nod to Johanna Trimble of IsYourMomOnDrugs? 

The CMA's incoming president for 2016-17 (our choice from BC), Dr Granger Avery, and our colleagues Drs Horvat and Routledge spoke to a disallowed motion that called for efficiency in our health care system. See their video here. Perhaps next year we can refine and submit more motions on appropriateness and efficiency? I have a few drafted already!

In a few narrow ways and in the broader sense, GC was a key step forward in advancing efforts for more appropriate health care. With a strong emphasis on addressing the real determinates of health, the solution of de-emphasizing tests and treatments that are harmful or not necessary also gains strength. Slowly, recognition for the importance of health in all policies is emerging. If a person cannot afford food, it doesn’t really matter if their dose of blood pressure medication is optimized. Right?

It feels fantastic to be a vocal part of an organization of 80 000 Canadian physicians that “get it.”

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...

BCMJ Book Review: The Patient Paradox: Why sexed-up medicine is bad for your health

At the Preventing Overdiagnosis conference last year in Oxford, I heard Dr Margaret McCartney speak. This is a passionate woman, one who advocates tirelessly for patients and follows the motto "Think critically and demand evidence." She is an outspoken leader, holding the NHS, her patients, her peers, and herself to high standards, eschewing conflict of interest and junk science.

I was lucky to meet her and when we talked further, Margaret handed me a copy of her book, The Patient Paradox: Why sexed-up medicine is bad for your health. Travel and work got in the way of me opening it, but when I did, I devoured it, underlining and folding and marking key points that resonated with me.

I have read many essays and a few books in the area of "too much medicine," and agreed with most of what they had to say. This book was different. It gained my trust by talking about things I already knew and accepted (more is not always better in medicine) and pushed me just outside my comfort zone, to question things I take for granted (eg the importance of pap tests). I admire the bold way in which she can push the already skeptical to challenge assumptions we didn't even know we had. Since I felt the need to share this book with others, I wrote it up.

You can read my piece about the book and its message in the July/August copy of the British Columbia Medical Journal (BCMJ).
 

You can buy the book from the publisher, Pinter and Martin here. If you want to read other reviews or get a copy on Kindle, Amazon.ca can help.* 

If you like the idea of reading more on the subject of "Less is More in Medicine," there are about 20 books in the Read section of the site, ranging in focus from cancer screening or overdiagnosis in psychiatry to patient-centered care, achieving evidence-based medicine, and turning healthy people into sick.

 

 

 

* I don't receive any kickbacks here, just hoping to make it easy to get the book in your hands

Source: http://www.pinterandmartin.com/the-patient...

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-...

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...

Minimally Disruptive Medicine: Thinking differently about nonadherence

In a follow up to Disutility: Finding the balance between benefit and hassle, I present this video from the North American Primary Care Research Group  (NAPCRG) Annual Meeting.

The answer to healthcare is education. Nevermind the other aspects of their life, nevermind that they have multiple diseases, side effects of medications, and not enough time in the day to do all the health 'work' that we give them . Teach patients, yell at patients, scare them into doing what you (the doctor) says. And if they don't take responsibility and do it, then... fire them as your patient!

Or not.

Dr Victor Montori, champion of Minimally Disruptive Medicine, explains a radical new way to think about "nonadherence" and the work that we give our patients to do.

NAPCRG Plenary I: Minimally Disruptive Medicine; Victor Montori, MD


Source: https://www.youtube.com/watch?v=cHSWDMH2rf...

"Less is More" Medical School Lecture

I had a great time on Monday presenting the "Less is More" concept with Dr James McCormack  to the 2nd year UBC medical students. I remember being in second year, struggling to memorize physiological pathways, neuroanatomy, an approach to diagnosing gastrointestinal bleeds, and at the same time being so eager to apply the knowledge in the clinical encounters we had. I can imagine it would be hard to hear "a lot of the stuff you are learning is important, but..."

We encouraged the students to take a step back, to remember they are caring for people (not diseases), and to use their critical thinking and common sense to partner with patients in decision-making. We emphasized the lack of evidence for much of what we do, the need to consider the harms of what may at first seem like benign tests and treatments, and to employ help (like Shared Decision Making tools) when talking with patients.

I've got some ideas as to what to include/exclude/change for similar talks I have lined up in the near future, including wishing I could bottle James' sense of humour and share that with everyone!

The questions from the students were keen, things like (paraphrased):

  • How can you approach these kind of ideas when a preceptor doesn't agree? (eg. one might feel pressured into giving an antibiotic for what seems to be a viral infection, because a supervisor insists)
  • What is the role of the provincial government, or what can they be asked to change?
  • Isn't overdiagnosis and overtreatment a function of physician payment schemes? Do we need to change the way we are remunerated?

Yikes! Next generation of healthcare, watch out! No one has perfect responses to these, but is exciting to exist in a time in which we are working on trying to answer these and other hard questions about the future of our health care system.

You can see a copy of our slides over in the Media/Talks section.

Personal Genomics: Is knowing MORE better than LESS?

Like the total-body MRI, it raises my eyebrows.

Are you SURE you want that?

Are you SURE you want to know every detail of what might be wrong with you, even if it might not actually be something causing trouble, and might be something that you cannot change?

For some people, the answer is YES.

For others, NO.

Personalized medicine, the kind of medicine that suggests individuals undergo genetic and molecular tests in order to develop customized care plans, is in the news. The Vancouver Sun has recently hosted an interesting series of articles all about this technology. It could save lives. And it can be an expensive, slippery slope. (See: Genome sequencing: A costly way to save).

Dr Brad Popovich, chief scientific officer of Genome British Columbia, discussed his own experience with genetic testing with the Vancouver Sun (Personal genomics: The test for everything (with video)). It is illuminating to read about the experience of a researcher and his questions moving forward. However, as staff and CSO of the organization, of course he needs to promote his work and his company's mandate; I'm not sure his experience is reflective of the average person's when thinking about genetic testing.

Another perspective is offered in the Sun by Dr. Matthew Farrer, Professor of Medical Genetics at the University of British Columbia (No quick genetic fixes for complex diseases). As he points out, it's nowhere near as direct a process for diagnosis as some might think:

“The average human genome gives you something like four million variants from one person to another. So, to interpret what those mean and what the consequences are to a person’s future well-being or susceptibility to disease is a pretty grey box.”

This article points out there may be an important role in mental health screening and lending clarity to diagnosis. Other articles document the benefits in assessing familial risk & individualizing cancer treatment or testing prenatally for conditions that are preventable or treatable if caught early on.

Unfortunately, there are lots of issues beyond the fact that this technology is in its infancy. Some things may improve as the body of research grows: the cost, the specificity, the availability. However, significant ethical issues may (rightfully) be a barrier to further advancement and application of this kind of testing.

Most diseases result from a combination of genetic and environmental factors. Some are predictable, and others less so. Some genetic predispositions never manifest as disease, or the disease can be more extreme than the tests ever suggest. That's the beauty of life - we cannot know the future. However, sometimes knowing what to expect can be helpful.

For example, in prenatal testing for Down Syndrome risk, some parents prefer to have an idea if their child might be affected so that they can read and prepare. Some parents may want to know about risk for the disease so they might choose to abort the pregnancy.  Other parents decline the testing because they will love and work with the child however they are born. Unfortunately, the testing is not perfect, there are many false positives and some false negatives.

The vagueness of genetic testing is a real challenge and may be confusing to patients as it may lead to greater uncertainty. As mentioned in the Personal genomics: The test for everything (with video) article, it's not only the patient who has to deal with the results:

Popovich’s decision, made with his wife Nicola, was made simpler because the two have no children. The presence of hereditary disease in his genome has no downstream impact . . .

Having your genome sequenced may have implications for your children, and the potential for this will have to be weighed before embarking on any such testing. Less importantly, there may be implications for life insurance and medical insurance eligibility, where universal healthcare is not available.

At The Conversation, Jacqueline Savard's essay, How genetic testing is swelling the ranks of the ‘worried well’ highlights some of the negative issues, particularly those under the umbrella of Overdiagnosis.

... genetic testing has the potential to give [patients] a label, adding them to a growing class of citizens, the “worried well”. These people are not ill as they don’t display symptoms of the condition with which they are labelled. Nor are they clinically diagnosed as having the disease in question. Instead, they are at a pre-phase, they are now genetically at risk for a particular disease. But the date, time, and list of symptoms they’re likely to experience or the severity of the illness are yet to be determined.

There are societal implications as well.

For society, the implications of genetic testing and over-diagnosis is the opportunity cost of treating the genetically at risk rather than those who are symptomatically ill. In the struggle for scarce resources, decisions are made between who and what diseases will receive the funds they desperately need.

Ms. Savard generously searches for a silver lining, but finds it to be false:

One potential (and limited) benefit of these tests is the creation of new markets for drugs or preventative treatments that can flourish as more people are labelled with conditions. But with health-care costs increasing and the need for rationing a central concern, there’s also the danger that resources will be diverted from public health measures that have a chance of preventing genuine illness in favour of treating “pseudodiseases”.

We don't need more disease. And we certainly don't need more diseases invented specifically in order to sell medications. But we do want people to live as well as is possible, at the same time allow the our natural course of existence to unfold.

As with everything, the answer probably lies somewhere in the balance. Perhaps a few very specific genetic tests will offer a cost-effective way to diagnose and even prevent serious ailments that are otherwise difficult to assess. The murky, inefficient, and ineffective tests can be abandoned so that we might focus on the other things that matter. 

If you don't feel sick and you are living healthfully (on your own terms), is that good enough? Isn't it?