Making change: The Right Care Movement

If you are reading this, you already know there is an epidemic of overuse in health care. Yes, there is underuse too, and this has been the subject of many lobbying and quality improvement initiatives to date. The medical-industrial complex, particularly in the United States, has capitalized on the fears of individuals who worry they might be victims of underuse, to the tune of billions in unnecessary and harmful "just to be sure" testing, medications, and procedures.

Of course the health of individuals and populations is primary, but we cannot discuss this in isolation, without due attention to cost and sustainability. Given the finite resources we have in health care, we can't afford to throw away the precious time of patients and clinicians, or the money of patients and taxpayers. The best way to fix either problem is to see them – under- and over-use – as one. We need the right amount of care.

Who doesn't dream of a problem in which all you have to do is shuffle the deck to solve it!? This resonates strongly with my predisposition (and tiny amount of training) with Integrative Thinking.

The classic example of two sisters splitting an orange is a good illustration of the potential of integrative bargaining, as well as its elusiveness (Follett, 1940). Two sisters both want an orange, and they compromise by cutting the orange in half. What they would have discovered had they discussed it, however, is that one sister wanted the pulp for juice, and the other wanted the peel for a cake. Discovering that they each wanted different aspects of the orange would have helped the sisters to split the orange in a way that each gets the most individual utility out of the agreement
– Kirk D, Oettingen G. Gollwitzer, PM. (2011). Mental contrasting promotes integrative bargaining. International Journal of Conflict Management, 22(4), 324-341.

This is not a traditional way of thinking. The idea that "less" can lead to "more" is not intuitive. Some examples may help to illustrate the meaning of this when applied to health:

1.By ordering fewer unneeded tests and consultations for one patient (say, to review their cardiovascular profile), the clinician can instead emphasize and support the role of lifestyle changes and free up the patient's time and energy to exercise (which will improve their health far more than any cholesterol test or drug could).

2. If a patient can stop paying for a medication she doesn't need, she has a better chance of making rent payments that month, decreasing stress and the morbidity associated with homelessness as well as reducing the chance of an adverse event or side effect from medication.

3. If one patient's MRI for a sore knee is cancelled because it was planned to assess for a meniscus tear and is not needed as meniscus surgery is not shown to be effective, then timely access is now an option for another patient who needs that MRI (perhaps they've clinically had a stroke and the CT was normal, so the pattern of pathology on the brain MRI would change the treatment plan to prevent further strokes)

It goes on. However, because many people don't think about the big picture for themselves, their practice, or society as a whole, it can be hard to convince them to consider the 'Less is More' mentality. They may only hear "less" and run screaming.

This is why we need to create a huge swell of support, a cultural shift to make the discussion about overuse and underuse the norm. Jeanne Lenzer explains more about how the Lown Institute is attempting this with the Right Care Alliance in The Backstory—Is US healthcare a frontier for a new civil rights movement?

Source: http://blogs.bmj.com/bmj/2016/05/13/jeanne...

A New Kind of Rounds: Type 2 Diabetes in the Elderly CME

Thanks to my local Division of Family Practice and the Practice Support Program (PSP), we were able to put together "A New Kind of Rounds" event all about helping patients find the right amount of medicine. 

Our first event, focussed on Type 2 Diabetes in the Elderly, and specifically the harms of treating this too aggressively. Inspired by the Lown Institute's RightCare Rounds and the DoNoHarm Project, we started with patient cases in which the patient's perspective highlighted the burden of treatment and the potential harms of too much medicine.

After small-group case learning, I presented a didactic session reviewing the unique factors that change our approach to management in the elderly, the best available evidence on diagnosis and treatment targets, the current guidelines, and some resources that clinicians and patients can refer to in order to make shared decisions about the "right amount" of care.

The event was well-attended and it was heartwarming to see the level of engagement on this topic from clinicians in our community; we are reviewing the evaluations to consider some changes to the format. Participants also generated an amazing of possible topics for future events, from hypertension to cancer-screening, and anti-psychotic use in the elderly to the annual physical. 

The slides are available here.

Your feedback is most welcome. You can comment below or e-mail. 

My other lectures can be viewed here.

Source: http://prezi.com/ln78vzbqpu4-/?utm_campaig...

RightCare Action Week: Get involved (LOWN INSTITUTE)

The Lown Institute is an amazing American organization devoted to transforming health care; particularly, they believe that performing unnecessary medical tests and treatments is unethical and unacceptable, and have undertaken work to empower patients and health care providers to achieve "the right care."

I had the privilege of attending their Road to Right Care conference in March of this year, and I am pleased to be able to promote the following initiative: 

RightCare Action Week

RightCare Action Week is a grassroots initiative for clinicians and others who want to take action that demonstrates how much better our healthcare system can be. 

Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations.

From Oct. 18 to 24, 2015, people like you across the country will take action to show patients that we have not forgotten what good medical care is. Actions can be as simple as taking a deeper social history or doing a house call.

What can you do right now? Sign up for RCAW, vote on actions you’ll support from our growing list of possibilities, or suggest one of your own.

Here are some themes you should consider before suggesting an activity for either a single day of RCAW or the entire week.

Actions that:

·      Highlight the conflict between the healing culture and business culture

·      "Suspend business as usual" 

·      Connect patients to clinicians and clinicians to their colleagues to provide better care

·      Encourage clinicians to take as much time as needed with patients

RightCareActionWeek.org is designed so that anyone can suggest or discuss activities on the forum.

The only way to transform healthcare is if we present what better healthcare looks like. RCAW is our chance to do that. Sign up to join us now.

RCAW is an initiative of the RightCare Alliance. 

 

For more information email us at organize@lowninstitute.org or visit us at www.rightcareactionweek.org

Source: http://rightcareactionweek.org/

Video: Emergency departments are for one thing only . . .

A really important part of appropriateness in medicine involves making sure patients get the right kind of care in the right setting, by the right provider.

For a laugh (on this serious subject) check out this new video from Queensland, Australia about proper use of Emergency Departments. [Feel free to share with patients]



BIG NEWS! QMA Unveils Action Plan for Overdiagnosis, Cost Savings

The Quebec Medical Association (QMA) just unveiled an Action Plan around Overdiagnosis!!

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This is an exciting day in "Less is More" !! This is a tangible and significant step forward towards making sure our patients get the right care.

Here is the hope- and awe- inspiring release, from the QMA

 

MONTREAL, Aug. 18, 2014 - The Québec Medical Association (QMA) is embarking on a new phase today in its effort to tackle the issue of overdiagnosis by unveiling an action plan that would allow major health budget savings. The plan is a result of concerted action between the main stakeholders in the health care system - physicians, representatives of medical and professional associations, the Collège des médecins du Québec and other professional orders, regional agencies and patient advocacy groups - subsequent to the first Québec Symposium on Overdiagnosis.

Following the release of this action plan, the QMA requested a meeting with the Minister of Health and Social Services, Dr. Gaétan Barrette, in order to coordinate the efforts to be deployed over the next few years to reach the expected results.

This action plan is the culmination of a process started in April 2013 with the publication of a discussion paper in which the QMA addressed the urgent need to optimize clinical practice in order to redirect approximately $5 billion to those activities that are most useful and relevant to patients. The goal of the action plan released today is to guide the actions that will be taken to reduce and prevent overdiagnosis. It presents the main orientations and potential solutions.

The issue of overdiagnosis generated considerable interest among the general public and health care stakeholders at the symposium and the launch of the Choisir avec soin campaign last April. The latest newsstand version of L'Actualité focuses on this priority issue for the Québec health care system.

Because overdiagnosis is a global phenomenon, the QMA's initiatives are also stirring international interest. At the suggestion of the well-known British Medical Journal, the QMA will give an account of its work and achievements in this area at the second international conference on the prevention of overdiagnosis in Oxford, England, in a few weeks. At the request of European government agencies/EU paying agents, the QMA will present the results of its efforts in November.

"Overdiagnosis greatly impacts the quality and accessibility of the health care offered to patients, and as a result, the efficiency of the entire health care system," stated QMA President Dr. Laurent Marcoux. "This problem has become a priority and we can no longer ignore it."


It will be exciting for me to meet the QMA representatives at the Preventing Overdiagnosis conference in Oxford this Sept and you can bet your bippy I'll be discussing this in BC with my Doctors of BC colleagues!