PODCAST: Preventing Overdiagnosis 2017 - from theory to practice by BMJ talk medicine

My first Podcast!

Dr Navjoyt Ladher of BMJ talk medicine kindly invited a few colleagues and me to participate in an informal discussion at the Preventing Overdiagnosis 2017 conference in Quebec, Canada.

As working clinicians, we explored moments in our careers that got us interested in tackling overdiagnosis, scratched our heads thinking a little bit about why we (and not all of our colleagues) are taking this on, and reflected on take away messages from the conference.

Have a listen, and go to the original site if you wish to join the discussion.

Source: https://soundcloud.com/bmjpodcasts/prevent...

VIDEO: #ChoosingWisely in Cypress Health Region

Since 2015, The Saskatchewan Health Quality Council has been moving forward the very important agenda of Appropriateness of Care.

 

In partnership with the Saskatchewan Medical Association, they have now launched Choosing Wisely Saskatchewan and are working engaging patients, clinicians, and learners to implement a province-wide strategy to tackle overuse. To start, they are focussing on pre-operative testing and imaging of lower back pain, and some of the health regions are taking on their own projects.

The Cypress Health Region has demonstrated their commitment to Choose Wisely:

Here's hoping many people will see their example and make the same pledge to choose wisely - because more is not always better in healthcare.

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

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

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.

Source: http://www.choosingwisely.ca

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.

The Upshot reflects: Patients overestimate benefit and underestimate harm of tests & treatments

In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.

Their Conclusions and Relevance section explains the take-away it nicely:

The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.

This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.

For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer. 

94% of patients overestimated the benefits of bowel cancer screening.

Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:

Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.

 These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.

Source: http://www.nytimes.com/2015/03/03/upshot/i...

Demanding Patients? Not so in Oncology

Surveyed physicians tend to place responsibility for high medical costs more on “demanding patients” than themselves. However, there are few data about the frequency of demanding patients, clinical appropriateness of their demands, and clinicians’ compliance with them.

Exactly. This JAMA Oncology paper looked at 5050 patient-provider encounters in the oncology context and found that patients requested things in 8.7% of the encounters, and these demands were only considered inappropriate in 1% of encounters.

Number and Types of Patient Requests or Demands (JAMA Onc)

Number and Types of Patient Requests or Demands (JAMA Onc)

I think we need to be very careful about blaming patients. I do it... but I'm getting better at seeing the bigger picture. Yes, sometimes they are in the stage of denial and struggling to cope with their diagnosis. They may ask for completely inappropriate tests or treatments. Sometimes their expectations are absolutely ridiculous but most of the time this is not the case. The patient is not crazy or 'demanding.' A lot of the time it is we clinicians who put some of the more unrealistic expectations on people's radar.

Educating patients wouldn't change this, except if we can encourage them à la Choosing Wisely to initiate discussions with their physicians about unnecessary tests and treatments.  Educating the clinician, particularly encouraging transparency and openness in communication is really important. However, the biggest thing we can do is to change the overall culture of the health 'system' and our society to make it "okay" to talk about these issues frankly.

I work quite frequently with oncology patients, often in a supportive or palliative role. I find it shocking that many of them have never discussed dying, have not made advanced care plans, and do not understand the goals of their treatment. Often a patient is receiving palliative therapy and yet they believe it is a curative therapy. They may demand aggressive medical treatment, not realizing that they are very close to dying.

Sometimes, when I liaise with the oncologist, he or she explains that they had frank discussions about these things, and I can see it in the notes. It's just been hard to accept and people don't really hear what has been said. Other times, "it just never came up." I find that that hard to believe. It should come up. Shouldn't it?

Not talking about the end of life is doing a patient a disserviceHow can they make decisions about their care without knowing what is going on? It also suggests - as made clear by this study -  that inappropriate interventions might be coming from the clinician, not necessarily initiated at the behest of the patient.

What do you think?

Source: http://oncology.jamanetwork.com/article.as...

Doctor, Shut Up and Listen (NY Times)

You've heard it 100 times, but perhaps this time it will sink in.

There's really no substitute for taking a thorough history of a patient and then supplementing it with a targeted physical exam, before considering any tests or interventions.

I'll admit, sometime I scrimp on the history (see below). I hate doing this because there's GOLD in the patient's words. You kind find out who they are, what is bothering them most, what they think is going on, and what you ought to do about it.

This is free, grade A info, and the only cost is time; filtered through a fancy medical education, what the patient says will guide everything. 

In the article Nirmal Joshi highlights the horrific results of crappy encounters:

Brief, rushed physician encounters were common, with limited opportunity for questions. A lack of empathy was often apparent: In one instance, after a tearful patient had related the recent death of a loved one, the physician’s next sentence was: “How is your abdominal pain?”

This past week, we were in the throws of influenza at our hospital. We still are. It was also the holidays and without the regular compliment of physicians, let alone Social Work, Occupational Therapy (OT), Physiotherapy(PT), Patient-Care Coordinators (PCCs), Speech Language Pathologists (SLPs), porters, Radiology Technicians, Phlebotomists, Pharmacists, etc. things basically ground to a halt. 

A lack of personnel and resources, combined with high numbers of new admissions, meant that everyone on my team was covering more than the usual number patients of varying acuity. And this, without the benefit of the usual allied professional help and expertise that we are dependent on working with to deliver high-quality care. So, time was limited. Simple questions to patients would be asked wherever possible, but I would never have left the building if I was being as thorough as I usually am. 

On the day where I started with a ward emergency (patients O2 Sats were 64%), I didn't eat lunch or take a bathroom break, another patient had new neurological symptoms and needed STAT imaging (and I got the radiologist to authorize it, but it still took 6 hours), a few other SNAFUs, and I stayed much later than usual, I simply could not find the time to practice a good 'ole H&P on every patient who warranted it. And I was very hungry!

I remember one patient with a complex story who was in for reason X but also happened to have problem Y (which was improving with treatment, but was initially life-threatening). The focus was on stabilizing the problem, which was actually going well. I expected the problems were related, and I could figure this out with a simple urine test. I did take the time to ask the patient about health problems, changes in medication, and to review the notes from specialists over the past year. But, with my phone ringing off the hook and patients needing to be seen, I didn't take the time to ask about some simple symptoms that might have helped steer the boat and figure out why Y had happened in the first place. I just ordered a lab test.

This is not something to be proud of, but I can certainly see how "Less is More" is sometimes easier said than done. I'm glad I'm conscious of the right way to do things but it is hard to always do that. Trying to find a balance between the mixed messages of "physician wellness is important" and "do everything beyond humanly possible to help people" makes it hard to end the day on a good note. 

I wish the system was structured in a way that the time and other pressures facing us didn't create situations where we have to choose between keeping sane (eg. taking a break) AND doing the right thing.

I'm nowhere near perfect but I really do enjoy getting to know my patients and playing "detective" to try to diagnose and treat their issues.

A lot of days, I miss my lunch.

 

Read the NY Times article HERE.

Source: http://www.nytimes.com/2015/01/05/opinion/...

Ask | Share | Know : Patient Resource for talking with your healthcare provider

Here is a snappy resource from Australia that can help patients (and advocates) create meaningful interactions with their healthcare providers.

The Ask | Share | Know project aims to empower patients to discover the information they need in order to make shared decisions with the health professionals they encounter. They suggest three key questions:

Asking the questions is a start, but even more important is the sharing of values and information with health care providers (HCPs). Patients have lives, values, and needs beyond their diseases, of course!

When your HCP can understand you and your needs better, they can help give you the knowledge you need to make an informed decision that goes beyond just medical facts and is tailored to your situation and goals.

Detailed follow-up questions, time to think, and opportunity to discuss with your main supports may also be needed before you make a decision. Try it out!