What Matters to You? Day - June 6, 2017

"What Matters to You?" Day is June 6, 2017! Ask What Matters. Listen to What Matters. Do What Matters.

 

Medicine is undergoing a huge transformation, shifting away from the historic model of paternalistic, top-down, doctor-driven health care. We started towards patient-driven, consumer medicine, and thankfully are starting to settle at a beautiful middle-ground, which is patient-centred care, using interdisciplinary clinician expertise, and a process of shared decision making around a patient's needs and priorities.

That is a lot of words, when really what it boils down to is this: shifting the emphasis towards caring for people rather than 'doing medicine.'

Or in even simpler terms, we should be asking "What matters to you?" and shaping the care we give to help people find the best fit for their goals. 

This is a new initiative in British Columbia, organized by the BC Patient Safety Quality Council (BCPSQC), to promote meaningful conversations around health care between patients and providers. "What Matters to You?" Day is based on a now global campaign that started in Norway in 2014.

We already incorporate this into our work in the Palliative Care and 'ED2HOME' services at my hospital, but I am keen to help spread the word for this very important idea so that all patients have a chance to answer the question.

From the BCPSQC:

Why does it matter?
Because we believe great care begins with a question. Providing patient-centred care is important because it results in better outcomes for patients and greater satisfaction with care. “What Matters to You?” Day supports this by putting the patient voice at the centre of care, by focusing on what matters to them.

When a health care provider starts a conversation by asking what really matters to the person they are caring for, it helps them to build trust, develop empathy, and understand their patients. Ultimately, it improves the quality of care they provide.

There are lots of ways you can support "What Matters to You?" Day

  • Join us & declare your intention to have a conversation about what matters, whether you're a care provider, patient, family member, or health care provider
  • Download our Getting Started Kit & learn more about the campaign
  • Order free resources to promote "What Matters to You?" Day. We've got posters, pocket cards, stickers, and more resources designed for patients and providers. We'll mail them anywhere in BC! 
  • Spread the word online using our simple, prepared messages and digital resources!
  • Get ready for conversations about what matters with our skill-building tools
  • Watch and share the campaign video, above

Celebrate The Virtual Launch!
We'll be sharing messages about "What Matters to You?" Day across digital channels, so join the conversation on Twitter, Instagram, or Facebook by using the hashtag #WMTY17! You can even add a #WMTY17 Twibbon to your profile photo to spread the word with every message you share!

Learn more: What Matters to You Day

Source: https://bcpsqc.ca/what-matters-to-you-day/

End of Guidelines (Video parody by James McCormack feat. ZDoggMD + friends)

James McCormack (@medmyths, BS Medicine Podcast) does it again!

Clinical Practice Guidelines must change! This is the end of guidelines as we know them.

Yes that is me and Gilbert Welch on the same screen. For realz!

Yes that is me and Gilbert Welch on the same screen. For realz!

We need patient centred care, including discussion of the values of the patient, the harms of intervention, and alternative options. Right now we have a bunch of arbitrary target numbers for treatment that medicalize normal people. These guidelines are mired in conflict of interest as the majority of guideline-authors having egregious conflicts of interest with industry. 

It's time to fix this! I'm honoured to be a part of this effort and call for action. It was awesome fuel for my imposter syndrome being asked to be in one of James' videos alongside some of my 'preventing overdiagnosis' heroes, not to mention ZDoggMD (whose videos I have followed for ages, probably since Hard Doc Life). The video features such like-minded pals including but not limited to: Gilbert Welch, Tim Caulfield, Iona Heath, Victor Montori, Richard Lehman and yep, yours truly - "it's just common sense!"

See for yourself and share widely:

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

End of Life Wishes: a (simple) Letter Project

The Stanford Medicine Letter Project idea is simple:

Write a letter that explains what matters most to you at the end of your life, how medical decisions should be made, and who can make decisions for you if you are unable. A formal advance directive can be intimidating to some. This is a straightforward way to make your wishes known.

Every adult should complete advance directives..... and most would, if they could! Sadly, many take one look at the advance directive form and give up after the first two minutes of trying to decipher the medico-legal jargon.

You can use their PDF template to start or fill out the form on the website and print or email the result for yourself, your family, and your physician(s).

In my work in Palliative Care, I continue to be amazed by the number of people I meet who have never thought or talked about dying. It is a natural part of life, guaranteed. It is one of the only sure things that we all have in common. And yet, so few people feel comfortable discussing it.

I am also amazed at the number of people who have thought about it extensively , have clear wishes, but have never made them known.

Don't wait! Talk to your family and consider this simple tool to share your thoughts and wishes.

Source: https://www.youtube.com/watch?v=vApg3qAn55...

Ten Commandments for patient-centred treatment | British Journal of General Practice

One of James' slides from a talk we did with an older version of the commandments

One of James' slides from a talk we did with an older version of the commandments

I first encountered the 10 New Therapeutic Commandments when I started working with James McCormack on a lecture for medical students at the University of British Columbia.

Evolving from the chapter ‘The new therapeutics. Ten commandments’ by John S Yudkin in The Good GP Training Guide, they've developed into something completely wonderful.

I expect these capture the practice philosophy of most people who are interested in "Less is More" and "Choosing Wisely," and looking at them now, I think perhaps we should have devoted the entire lecture to this one slide.

See for yourself, the list and explanations, in the British Journal of General Practice.

 

My top 3 from the 10

1. Thou shalt have no aim except to help patients, according to the goals they wish to achieve

I think this could be the modern version of the most eminent aspect of the Hippocratic oath; not doing harm becomes respecting patient goals above all else)

2. Thou shalt always seek knowledge of the benefits, harms, and costs of treatment, and share this knowledge at all times

It is impossible to have an informed discussion and consent if one isn't informed.

7. Honour thy older patients, for although they often have the highest risk, they may also have the highest risk of harm from treatment

Exactly.

. . . 

Look at the list to see the rest!

 

Source: http://bjgp.org/content/65/639/532

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...

VIDEO: Good Stewardship / Model conversations with patients about overtesting and overtreatment

The National Physician Alliance (NPA) has done a lot of work in the area of preventing overdiagnosis and empowering patients to find the right amount of care. They are a partner in the Tandem Health project/app, created Top 5 lists (in good stewardship) which served as a model for the Choosing Wisely Campaign, and promote responsible prescribing (by limiting influence of the pharmaceutical industru) through The Unbranded Doctor.

Created in 2011, this video is a timeless tool for Good Stewardship. It gives a simple, 5-step plan of how health care providers can discuss unnecessary tests and treatments with patients.

They suggest:

1. Clarify what the patient’s true concerns are
2. Provide the patient with the information he/she needs to understand the plan
3. Be courteous and respectful
4. Provide clear contingency plan
5. Make sure the patient is satisfied with the plan
Source: https://www.youtube.com/watch?v=kh7EKP9wSg...

VIDEO: Making Decisions With, Not for, Patients

Dr Victor Montori (@vmontori) is a leader in the area of shared decision-making (SDM) and minimally disruptive medicine.

In this interview by his colleague, Advanced Cardiology Fellow, Dr Selma F Mohammed, Dr Montori highlights what shared decision-making is, why it is important, whether patients want it, and how to do it.

The video is a great introduction to the idea, and could be a wonderful teaching tool for medical students or clinicians in practice.

Montori holds our feet to the fire:

It all starts by caring enough to engage the patient in the decision-making. Many people argue that
     'We don't have time for this in the consultation. I'd rather just tell people what I think is best for           them and then they can decide whether they want it or not.'
Well, that's not very caring. This might be efficient, but it does not reflect the best that we can offer.

This guy is my hero!

Watch the video:  Making Decisions With Not for, Patients

If you like the idea of the shared decision-making tools they mentioned, check out the Less is More Medicine's collection of different ones in the Hands-On Tools section.

Source: http://www.medscape.com/viewarticle/844541

What Can Patients Do In The Face Of Physician Conflict Of Interest?

I had the pleasure of meeting Dr James Rickert, an orthopedic surgeon and a patient, at the Road to Right Care conference put on by the Lown Institute in March. Dr Rickert works with the The Society for Patient Centered Orthopedic Surgery, advocating for health care reform and patient care that puts the patient in the centre.

One of the topics that he writes and speaks about frequently is conflict of interest in medicine and the financial incentiviazation of care which may be unnecessary or harmful to patients. 

To that end, his most recent contribution to the Health Affairs blog, What Can Patients Do In The Face Of Physician Conflict Of Interest?, describes some the major issues that emerge when caring becomes a business. There are also suggested Action Steps for patients to take when confronting these concerns.

Strong relationships between patients and providers are the heart of healthcare; we must work together to improve our culture and hold providers to a high ethical standard to stop the erosion of trust.

Source: http://healthaffairs.org/blog/2015/04/10/w...

Day 2 of Road to #RightCare #Lown2015 Recap

This old photo came to mind as I thought about how people tell their stories:   Some graffiti at the skate park in Inuvik, NWT; Is it a profound statement about the way things are imposed on people without ever asking them or listening to them?  Maybe it's just  some teenagers upset about not having enough weed. 

This old photo came to mind as I thought about how people tell their stories:

Some graffiti at the skate park in Inuvik, NWT; Is it a profound statement about the way things are imposed on people without ever asking them or listening to them?  Maybe it's just some teenagers upset about not having enough weed. 

Today was about people.

What I kept hearing today was that patients are people, people have goals and values, and they need to be asked and heard. 

---

We started with Dr Harlan Krumholtz explaining that the right care "is about an informed patient, with an informed choice, based on the right information." Given the real information, a person can decide whether the potential risks or harms of some test or treatment are worth accepting, for the potential benefit of that test or treatment.

Peter Drier, an articulate non-healthcare professional, told his story about being a patient and being the recipient of a (surprise!) $117k bill from a consultant (who he never met) that spent a few hours assisting in the Operating Room. This was in addition to the original agreed upon bill for his surgery. As he told his tale of attempting to navigate a rats-nest of a system that it seems purpose-built designed to bankrupt patients, I was alarmed. Dismayed.

How could you possibly navigate this while also coping with disease? How could vulnerable patients survive in this system? How could doctors ethically accept they were a part of it?

Others in the room thought that getting a patient help to navigate the system would be a good fix. Or maybe publishing prices in a transparent way would help. Wait... what?!

I was shocked to see that people have accepted this system. Rather than challenge the status quo, they seemed resigned to work with it and plan to bodge together some work-arounds and bandaids. Incremental change is sometimes a good solution but when you have a system that toxic, how can you let it persist?

I started really worrying, worrying about the case that surgeon Dr Brian Day has before the BC Supreme Court, which if successful, will pave the way for patients to pay privately for medically necessary procedures. I try to envision a world in which this helps patients, but that future looks like the US of A, and in the US of A, health care is broken, in a far more challenging way than it is in Canada.

But, there are bright spots! In a workshop on designing the future of Primary Care, we learned about the model of the Stanford Coordinated Care Team. It puts patients at the centre and offers them multidisciplinary support to engage them in achieving health, and does so by asking team members to rise within their scope to manage care and build relationships.

Through Beyond Workups and Rule-Outs, we explored the unique drivers of care in the Emergency Room, like time pressures and fear of missing a diagnosis. We brainstormed solutions for the culture and process, and I was pleased to be able to share the (often hated in medical school but valued later in practice) "FIFE" model. This aims to aid patient-centred interviewing, to get at the person rather than the disease or symptoms:

This model forms the backbone of the Family Physician certification exam in Canada.

There were lots of other ideas about helping patients get in and out of the ER "well" and one idea for changing the culture of practice that I really like is "reverse M&M rounds" which may be the same thing as "Right Care Rounds." There was a separate session on this topic I didn't get to go to that session as there was too much simultaneous good stuff; regardless, I am inspired to attempt (time permitting) case rounds back home about inappropriate (unnecessary) care, whether it caused an obvious bad outcome or one that was a bit more subtle.

In the same vein, The Do No Harm Project presented some wonderful 'vignettes' or narratives from residents, highlighting 1) how common medical overuse is and 2) how persuasive a patient's story can be. 

Tomorrow we decide how we will take what we've learned and commit to putting it to work.

Patient Story: Adventures in Choosing Wisely

Here's an awesome example of a patient who worked with her doctors to Choose Wisely.


Amy Berman has breast cancer that has metastasized to bone. She is a Registered Nurse (RN), a Senior Program Officer at the Hartford Foundation, and a vocal advocate for patient-centred care.

She decided with her doctors that she would benefit most from treatment with a single fraction of palliative radiotherapy instead of an extended course. The goal of this being some relief from the pain that stemmed from the new area of cancer on her ribs.

Her choice is in keeping with the evidence and recommendations of the Choosing Wisely items in Radiation Oncology. In the USA, the guidelines developed by The American Society for Radiation Oncology (ASTRO) suggest:

  • "Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases." 

 The Canadian Association of Radiation Oncology, in their version of recommendations, suggest:

  • "Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis."

Further, they explain: "Randomized trials have established that single-fraction radiation to a previously unirradiated, uncomplicated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared to multiple-fraction regimens, while optimizing patient and caregiver convenience. Although it results in a higher incidence of retreatment at a later date (20% vs. 8 % for multi-fraction regimens), the decreased patient burden usually outweighs any considerations of long-term effectiveness for those with a limited life expectancy."

Arranging this appropriate treatment was harder for Amy (and her doctor) than just making the choice. See her blog post to find out more, as there was more to the story! It appears that not everyone is on board with Choosing Wisely, yet  . . .

Source: http://www.jhartfound.org/blog/adventures-...