How do you know? Fact, fiction, alternative truth?

Humanity has explored many ways of knowing, from trusting deities and their 'earthly conduits,' to seeking out experts, to looking for evidence and statistics, to believing what one feels is 'right.' I am fascinated by epistemology (the investigation of how we know things, of what distinguishes justified belief from opinion) and the psychology of choice, but I am even more interested in what we can do to promote critical thinking.

 

How do you raise children to question the statements that they hear?

How do you inspire patients to develop their health literacy and explore how probabilities are presented to them?

How do you convince policy-makers to consider value rather than throughput in their decision-making?

Can we convince health 'experts' to include effectiveness, the risks, and costs of various interventions when they write guidelines?

Apparently the heat from climate change has fried our leader's critical-thinking brain centres, and we now find ourselves awkwardly in an era of supposed "alternative facts." We know that fighting firmly held personal beliefs (even if we consider them lies and delusions) with facts is not effective; however, if you a reading this then you are already probably a bit skeptical, and you can explore the resources below to help with your own decision-making.

 

HERE ARE A HANDFUL OF PUBLICLY-AVAILABLE TOOLS TO HELP:

 

1) A book: Know Your Chances - Woloshin, Schwartz, Welch - FREE Online via PubMed

Every day we are bombarded by television ads, public service announcements, and media reports warning of dire risks to our health and offering solutions to help us lower those risks. But many of these messages are incomplete, misleading, or exaggerated, leaving the average person misinformed and confused. Know Your Chances is a lively, accessible, and carefully researched book that can help consumers sort through this daily barrage by teaching them how to interpret the numbers behind the messages. . . The book's easy-to-understand charts will help ordinary people put their health concerns into perspective.This short, reader-friendly volume will foster communication between patients and doctors and provide the basic critical-thinking skills necessary for navigating today's confusing health landscape.

[some other books about overtesting, overtreatment, and being skeptical in medicine are listed HERE]


2) A video: How to spot fake news

This video highlights the need to be skeptical and question headlines on social media or on other sites; it's sometimes hard to tell if a story is fake. If something seems shocking or strange, it's a good idea to ask around and do a bit of google-sleuthing. Checking the date, the source, and asking a skeptical friend can help you figure it out.
 

3) A website: Testing Treatments Interactive

The TTi site contains learning resources to help people recognise and understand Key Concepts, and how use them to evaluate treatment claims. These are categorized by concept, target learning group (kids, undergraduate students, etc), and the format (videos, websites, cartoons, etc). The book is also free and available in audio, PDF, or HTML format.

4) A guide: 12 Questions to Ask: How to Evaluate Health Information on the Internet

The National Institutes of Health has put together a great tool to help patients and caregivers check the reliability if information from the internet. These 12 straightforward questions can help you decide if what you are reading is useful - or useless.

Do you have other tips for getting to the truth? 

Source: https://www.amazon.ca/Know-Your-Chances-Un...

Wake up and smell the #overdiagnosis

Alan Cassels is not a shy kind of guy. He tells it like it is and is not one to stay quiet even if what he says may be unpopular. 

And usually it is pretty unpopular. 

However, it is necessary. From calling out the BC government's inaction on Choosing Wisely to fighting the overmedication of Canadian seniors and digging into the Sex, drugs, and rockin' beat of tramadol and tramacet's marketing machine, he is not afraid to talk about the elephants in the room, when it seems no one else is willing.

 

Cassels is a policy analyst, author, and champion debunker when it comes to pharmaceutical policy and the medicalization of Canadians.

In his most recent article for Focus Magazine, Cassels highlighted the Preventing Overdiagnosis conference, the harms of prostate cancer screening, and my perspective on the issues. 

I've had the chance to work with Cassels on a few small projects but to be called a 'resistor' by him feels like quite a pretty high honour! Check it out in Focus.

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.

 

Difficult patients. Sigh! (Impact of patient requests on provider-perceived visit difficulty in primary care)

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

Sometimes physicians talk about the "difficult" patient with exasperation in their voice.  Nurses know these cases even better.

Most patients and families can tell your about a doctor or nurse who was terse, arrogant, disinterested, or even callous.

These encounters can be "soul-sucking," "difficult," and "draining." The individuals are labeled as "entitled," "unrealistic," "demanding," or ... worse.

That's not ideal terminology although the truth is that some patient encounters are harder than others, and we can't always figure out why. If we have a frustrating appointment, we equate the difficulty with the person, not the situation. As physicians, we often blame the patient!

"It's a personality disorder." "She's a rich, demanding snob." "He refuses to accept this."

On the surface are our attitudes, biases, and skill sets. Just like "difficult" doctors, "difficult" patients are, in our eyes, not open-minded, have not mastered skills of effective communication or listening, don't want to be told they are wrong, demand ridiculous things, or dig their heels in despite evidence that contradicts them.

Sometimes stubbornness is advocacy and it is necessary. Sometimes asking lots of questions is essential to developing an understanding from which a partnership can follow.

There is usually more to the story than just a clash of the personality of the clinician and the patient, and the health care provider should be sensitive to this; empathy means acknowledging that other people have "stuff" going on in their life. Fear, anger, embarrassment, uncertainty, and anxiety are among the many emotions that can make a clinical exchange sour.

With time and worldliness, and maybe some training, we grow and learn to help sort through that. Interestingly, the kind of encounters that health care providers find difficult are generally around people asking for tests.

According to Fenton et. al's paper, Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care, in the Journal of General Internal Medicine:

[Primary Care Provider] (PCP)-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of “choosing wisely,” PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider–patient relationship and PCP career satisfaction.

They looked at 824 clinical encounters. Even adjusting for medical and psychiatric conditions, it was asking for tests that made clinicians rate the encounter as more difficult.

Fortunately, there are tools to help with this. A (not well curated) collection of Shared Decision Making tools is available on this site. Another time, I'll write about the evidence of efficacy (or lack thereof?) behind these aids.

The Choosing Wisely campaign is a prominent effort to facilitate these conversations about unnecesary tests. The Canadian and American sites both have many educational resources to help us with discussing diagnostics and therapeutics, and the AAFP has a great article on difficult patient encounters

It's not rocket science. We must remember that patients are human beings. Hopefully they will extend us, as providers, the same consideration.

At least he used the sensitive kind of tooth paste?

At least he used the sensitive kind of tooth paste?

Finally: yes, some people, whether doctors, patients, nurses, or family members, are just plain jerks.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2537383...

When the nurse told me "less is more"

I was called to the emergency room to admit a very ill patient. With sepsis and an MI, this frail elder probably wasn't going to do so well.

“He’s pretty sick, eh?”
“Yah. Poor guy.”

The nurse and I paused, resigned to the fact that this elderly man was nearing his end and there was little we could do to change that. I think we both sighed at the same time.

I entered the room and talked to the patient and the family at length. They showed me a photocopy of the DNR form he had signed years ago. He didn't have any kind of advance directive, and had rarely talked about the process of dying, aspects of medical treatment, or what his goals might be for the remainder of his life.

At home, he spent most of is time in bed. Mobility was a bit shaky with a walker so it was safer to stay put. Poor hearing, shoddy vision, and mild dementia made it nearly impossible for him to read or watch TV or to do much of anything, really. He still beamed during visits from the grandkids. His daughter told me that she thinks he had been depressed for a long time; every second day he would say that he was ready to die.

I stepped closer to him. The laboured breathing didn’t look any better close up. He did have the breath to tell me, “I’m dying.” When I discussed the various range of treatments from comfort care (treating pain and respiratory distress), to medical management (antibiotics, blood thinners), to aggressive medical therapy (maybe some non-invasive support for breathing), he said that he wanted to die.

Was he just feeling terrible because his heart had jammed from the strain of fighting off a systemic infection, something that would be exhausting and uncomfortable even on its own? Or was this an expression of considered hope for an end to his now languid existence?

It wasn’t easy to communicate clearly or in detail. I asked more questions, but he said little. Even with a raised voice, I don’t know if he could hear me. His family was uncertain about what he would want done. It was clear that anything aggressive was not right. With failed kidneys, I’d have to give an IV blood thinner (heparin infusion) with up to 4x a day lab tests to prevent worsening of the heart attack. His breathing might get worse and if so, could be helped by strapping a machine on his face to push and pull air in and out of his lungs. That seemed cruel.

But, should I still offer some minimally invasive things that might improve both quality and quantity of life? Antibiotics might help the breathing to get easier and give him a chance of surviving. But this might also just delay the inevitable, prolonging suffering.

I try not to be wishy-washy and give patients and families clear recommendations, but it is hard. When people’s values vary so widely, and there are several avenues that might be appropriate, I don’t feel I can make the decisions for them.

I try really hard not to push my belief in “less is more medicine” too far. I don't want patients to be denied opportunity for healing and improvement. Just as I feel very strongly about doing less of the unnecessary things and interventions that will give more harm than benefit, I also feel very strongly that patients should have timely and meaningful opportunity to have the tests and treatments that might really benefit them.

“What do you think he would want? Is that consistent with his wishes? . . . ”

After I finished talking to the patient's family, I confirmed the plan with the nurse. We would keep the antibiotics and a few heart medications, but for the most part emphasize comfort. I left orders for adequate medications for pain, respiratory distress, and restlessness, to be used regularly if needed. If he got worse, we would stop the antibiotics. I didn’t think they would really help him but his family wanted to try. Although they would not want to extend his distress, it was all pretty sudden and not treating potentially reversible things was different than ensuring he was comfortable while dying (when no reversible causes remained).

It felt like we had arrived at some understanding of the medical reality, the patient’s wishes, and the substitute decision makers’ needs. As I discussed this and explained to the nurse that it wasn't maximum medical therapy but that it seemed a reasonable approach. Nurses, especially those who've got experience under their belt, seem to have a kind of wisdom that comes from the direct care of patients like these.

She looked at me and said "well, you know, less is more."

My colleague, an ER-physician who was in the same residency program as me and knows my passion, was within earshot. She chuckled.

A big smile stretched across my face, and I started looking at my list to find the next patient.

Patient-Friendly Portal for Choosing Wisely Canada

Choosing Wisely Canada (CWC) has been on a roll lately with some exciting initiatives, including reaching out and empowering medical students to be leaders for change.

They've also just launched the patient-focussed part of the website, started ramping up the 10 million challenge, and upped the PR push to advocate for culture change with the slogan "More is not always better."

I love that the campaign is growing beyond creating lists about unnecessary and harmful tests and treatments, and blossoming into a strong organization that is beginning to tackle some of the drivers of overtesting and overtreating at the root of the problem.

I always worried that CWC wouldn't do enough "big picture" stuff, but I am so very glad to be proven wrong!

 

Check out the new patient portal or join the 10 million challenge, a Canada-wide collective action initiative to help prevent 10 million unnecessary tests and treatments by the year 2020. And, keep a close eye on Choosing Wisely Canada because I have a feeling there's a lot more to come!

Source: http://choosingwisely.ca/

Wisdom Teeth: Extracting some meaning

Ow.

Wizzie glamour shot! Day 3?

Wizzie glamour shot! Day 3?

My chipmunk cheeks are NOT cute.

I have had the privilege of being a patient on a few occasions, some less serious (Bells Palsy, Pityriasis Rosea) and some more serious (Transverse Myelitis). I'm fortunate to be pretty healthy overall and try to steer clear of trouble.

I do go to my GP who is an amazing full-scope, old-school, dedicated doc. Even though I think he's amazing, I still say "no" sometimes. Most recently he suggested some screening blood work, and I declined. He gave me the requisition anyway, but needless to say I did not donate any blood to the cause.

With that said, it will come as no surprise that I never wanted my wisdom teeth out. 

Healthy Debate has a timely article, Is wisdom teeth removal really warranted?, covering all the evidence and the information one needs to make a decision about whether to get impacted teeth extracted. 

My wizzies (that's what cool kids call wisdom teeth) were sitting in my mouth, just being teeth, maybe impacted but not really causing any trouble. Until... they started to peek out in my 20s, and now age 30, one of them (right, lower wisdom baddie) created an unreachable space between him and his neighbour molar. Boom! Infection. Periocoronitis. Yuck.

I did all the conservative stuff and tried to keep baddie's space clean and happy but no matter the fancy syringe or amount of peroxide I blasted in there, the infection continued, slowly smouldering. My dentist suggested I see the oral surgeon.

He also suggested a bunch of other things, like braces, which I said no to. While I am fortunate enough to have a great dental plan, I did not want the headaches and hassle of that just for cosmetic reasons and the chance that it would slightly improve the way my teeth were wearing. Dr Dentist listened to me and agreed. That was nice! The alternative of leaving my wisdom teeth in would be possible, but the infection would wax and wane and it could do this when I'm out of the country or could require repeated courses of antibiotics, visits to the dentist, etc. So I agreed to go see the oral surgeon (Dr Surgeon) who said all my teeth definitely needed to come out.  Oh, and I'd need a CT scan first to see if the tooth roots were wrapped around the inferior alveolar nerve. 

Dr Surgeon was awesome at discussing the risks. He also offered an alternate plan if the teeth were intertwined with the nerve. The CT really wasn't optional, as it was needed for planning the technique. I asked if I could just get baddie out, but he suggested it was better to do all of them at once so I wouldn't have to go through the surgery later in life if there were more issues. Getting wisdom teeth out after 25 is not ideal to begin with, and doing it on 4 separate occasions (if needed) would indeed be torture. 

The reason wisdom teeth are much easier to remove in teenagers is that the teeth don't contain much wisdom at age 18

Now, my jaw is recovering from having a crowbar go exploring in it. Well, actually I'm sure Dr Surgeon was as gentle as possible but they were stuck in there pretty well. My right side (where the infection had been) healed very well, the left basically did the maximum amount of swelling/trismus possible and I even got a shiner. Round the clock ibuprofen, lots of ice, etc. was somewhat helpful but mostly it just took time to settle.

Compared to others who've had the same surgery, I got off easy. My inferior alveolar nerves were fine. I didn't get a nasty infection like my brother did when there was a perforation into his sinus(!). I didn't die from complications of the anaesthesia. Phewf!

Every time I am a patient, I learn things about myself and especially about doctoring.

If I look at this from a patient-centered experience, I would say there were some good things:
- able to schedule it at a time that worked for me
- very clear and upfront about the price, the risks, the recovery process
- printed instructions were very detailed and included contact info for the surgeons
- the clinic called to check up on me
- when a large fleshy lump developed inside my cheek, they were able to fit me in quickly and verify that it wasn't an abscess, reassuring me + my spouse
- I hardly ever had to wait in the clinic, everything was basically on-time which was incredible!

 

Popcorn Addict. Used (unfortunately without permission, but it's too perfect to not post)  from Sam on Flickr

Popcorn Addict. Used (unfortunately without permission, but it's too perfect to not post) from Sam on Flickr

On the other hand, there were a few parts that made it hard to navigate:
- one side of my jaw was not bad and the other with terribly terribly painful, which made me wonder if some complication was happening, it would have been helpful to know that this is "common"
- I was given a prescription for antibiotics; this was not mentioned in the handout or by the surgeon to my spouse so I was unsure if I should take them or if they were a delayed prescription (eg. take if a complication arises); when the clinic called to check on me the day after surgery I asked the caller whether I should take the antibiotics. She said "yes, of course." And I tried to clarify, "oh, I wasn't sure if everyone takes these or if they were just if some complication developed; I didn't want to take them without being sure because of the risks of antibiotics" and she told me "there aren't any risks."
[I got a bit upset at that point! Maybe it was the gnawing jaw pain or maybe I was just outraged... I might have mentioned that I was a physician, a card I try not to use because it makes me feel like an entitled a*hole, and that 'yes indeed there are risks...'] 
Anyway she told me it was routine and I relented. My scan of the evidence didn't confirm that, but because I'd had a chronic infection pre-op I figured Dr Surgeon would probably strongly recommend I take them. I probably could have handled that better by asking about it earlier in the process, but I didn't know there would be antibiotics until I emerged from the post-anasthesia haze at home
- the handout was great but I wish I would have received a copy before the day of the surgery; one of my values as a patient is "eating popcorn" and I was a bit sad to find out on the operation day that I would not be allowed popcorn for 3 months!!!!!!!!

What I might apply to my own practice:
- handouts are useful!
- people like to know what to expect, so it's good to invest the time explaining some of the possibilities and timelines
- when doctors or clinics are accessible, it helps! Even if you don't need to call or go there, somehow it feels better knowing that if you need them, it is not impossible to reach them
- when estimating recovery times, it is probably better to under-promise/over-deliver; I was told to have 3-5 days off work and I wound up needing 7 before I even could see properly out of the eye on the side that was swollen/bruised and open my mouth wide enough to speak clearly
 

In the end, did I get the right amount of medicine? Maybe. I'm not sure! In hindsight, I would certainly have asked a few more questions (eg. about antibiotics) and I might have opted for removal of just the one baddie wisdom tooth.

Overall it was very challenging being a patient with a background in health care. When I went numb from the waist down two years ago, I basically dismissed it for three days before my dad (a nurse) insisted I seek attention - and there turned out to be an inflammatory lesion on my spinal cord ('transverse myelitis'). So now, I try really hard to mention things that seem odd or wrong and let other doctors decide if they are important. The consequence of that is that I probably come off as a worrier, but I'm sure I'll find a balance with more adventures as a patient. 

I just hope this is all the medical adventuring I'll have for a little while, at least.

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...

Disutility: Finding the balance between benefit and hassle

James McCormack (@medmyths, The Best Science Medicine Podcast) sent me a great article: "Patient-Accessible Tool for Shared Decision Making in Cardiovascular Primary Prevention."

The UK group looked at the problem of patients discontinuing medication and focussed in particular on statins for primary prevention of cardiovascular events. A lot of research assumes that the 'burden' of taking a pill is a negligible factor in medication adherence, but these researchers thought otherwise. They surveyed 360 people to see how they might balance their potential cardiac risk with the 'disutility' of a preventative, once a day medication as intervention. Paraphrasing, they wanted to know:

how much longer would a person need to live (thanks to a medication) in order to make it worth the hassle of taking the medication

The article is worth sharing because it introduced a few new ideas to me:

  • "disutility" : a word the researchers use to capture the idea of inconvenience or burden of care
  • there is some good evidence that educating people more and more about their risk will not change their adherence to medication
  • talking about reasons they would not want to take the medication may be more important
  • as every person has a different tolerance of disutility, individualized discussions (shared decision-making) still remains a good strategy
  • for people who fall in the middle ground when balancing utility and disutility, factors like gender, smoking, blood pressure, and cholesterol factor into the decision whereas they do not for those with high or low disutility

Figure 4.

Disutility vs utility. Frequency distribution of disutility, longevity benefit that subjects expressed a desire to make tablet therapy worthwhile (top), and the frequency distribution of utility, actual expected gain in lifespan from statin therapy in the English population (bottom). The difference between the 2 values is the net benefit of tablet therapy. Because utility has a very much narrower spectrum than disutility, for those with a high disutility, regardless of utility, statins are a net harm; for those with low disutility, regardless of utility statins are a net benefit. It is only for those in the middle gray zone (top) that sex, smoking status, blood pressure, and cholesterol are the deciding factors.

Read the full article here, in Circulation. 

If you are very interested in the idea of 'disutility,' you may enjoy Dr Victor Montori (@vmontori)'s work on "Minimally Disruptive Medicine."