My talks at #FMF2016: Goldilocks approach to DM2 in elders, and Less is More Med

I'm really excited to be at FMF 2016 in Vancouver this year! It was two years ago in Quebec City that I presented on Less is More Medicine for the first time, and it was an incredible experience. 

I got to see this message resonate, empower the audience of my peers to act and improve their every day practice, and learn from them about the challenges and successes along the way. I can't wait to do it again!

Slides and handouts (you asked!) will be posted after the talks in the media/talks section.

Is it worth it? The role of Health Technology Assessment (HTA) and using evidence with patients

"These are my people," I thought to myself on the long plane ride West, destined for home to a verdant explosion of nature after three days in snowy Ottawa. Maybe it was the season, but I think it was more the people around me that reignited my enthusiasm for change in health care.

In April, I was invited to Ottawa to be a part of the Canadian Agency for Drugs and Technologies in Health (CADTH) symposium closing plenary on the subject of Health Technology Assessment (HTA), a term that I had (embarrassingly!) not really heard of until receiving that invitation.

Despite feeling woefully out of place as a mere clinician, surrounded by successful policy analysts, clever researchers, health economists, and seasoned advocates, I had an incredible time. As I milled about taking in various presentations and getting my feet wet as part of a panel on Disinvestment, I found myself suddenly realize: everyone around me "gets" it.

What a gift: when you are asked to share your passion, say whatever you want to say, and know that the people listening are listening and nodding "yes" to some of the things that fall out of your mouth?

As I think more and more about how I can have a positive impact on the health and well-being of people, I think about the role of HTA in policy change, and about how evidence belongs to everyone. Being a bit camera-phobic I was reluctant to highlight this 8 minute video, but it was an honour that I do not wish to squander and I hope that some of what I said resonates with you too.

The 2017 CADTH Symposium is Apr 23-25, with the theme "Measuring Value in Theory and the Real World." If you are a student or patient group representative, you may be eligible for a travel scholarship. Check it out!

ATTN: Edmonton, Feb 3, 2016 Picard Lecture: Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care

Gilbert Welch (img used without permission,  Beacon Broadside )

Gilbert Welch (img used without permission, Beacon Broadside)

I just learned of this event in Edmonton, on Feb 3rd. Don't miss it!

Welch is a persuasive champion of 'less is more' in medicine, and his talks are inspiring, dynamic, and necessary. If you can't attend, check out his latest book, Less Medicine, More Health. RSVP details below. - J.


From The University of Alberta (original post):

"Many doctors are worried about the problems caused by too much medical care. A recent survey suggested that nearly one-half said their patients received too much medical care. But it is hard to communicate the nuances – that medical care can do a lot of good in selected settings, but can also do harm in others – during a 10-15 minute clinic visit.

Doctors like to blame lawyers for the problem of too much medical care. But ask yourself this: Would the problem of overuse disappear if the lawyers disappeared? Economists like to blame economics. But the recipe of adding fee for service to third-party payment to cook up too much medical care would not work without strong underlying beliefs about the value of the product. The general public harbors assumptions about medical care that encourage overuse.

I’m not blaming the public; many of these assumptions flow directly from information provided to them – be it from the news media, talk shows, advertising, PR campaigns, disease advocacy groups, public service announcements or doctors themselves.

Regardless of their source, these assumptions lead individuals to have an excessively optimistic view of medical care. That leads them to seek – some would say to demand, others to accept – too much care.

February 3, 2016
12:00
McLennan Ross Hall (Rm 231/237), Law Centre (111 - 89 Ave)
University of Alberta - Edmonton, AB

Please RSVP here.

Dr. Welch is a general internist and professor of Medicine at the Dartmouth Institute for Health Policy and Clinical Research in the Geisel School of Medicine. He is also a professor of Public Policy at Dartmouth College and a professor of Business Administration at the Amos Tuck School.

For the 25 years he has been practicing medicine, Dr. Welch has been asking hard questions about his profession. His arguments are frequently counter-intuitive, even heretical, yet have regularly appeared in the country's most prestigious medical journals — Annals of Internal Medicine, Journal of the American Medical Association, the New England Journal of Medicine and the Journal of the National Cancer Institute — as well as in op-eds in the Los Angeles Times and the New York Times. His most recent book is Less Medicine, More Health – 7 Assumptions that Drive Too Much Medical Care.

Dr. Welch is very much part of the “Dartmouth School” that questions the assumption that more medical care is always better. His research has focused on the assumption as it relates to diagnosis: that the best strategy to keep people healthy is early diagnosis – and the earlier the better. He has delineated the side-effects of this strategy: physicians test too often, treat too aggressively and tell too many people that they are sick. Much of his work has focused on overdiagnosis in cancer screening: in particular, screening for melanoma, thyroid, lung, breast and prostate cancer."

Health Care Social Media #hcsm - Using it for advocacy & Prezi slides

I have used social media extensively to advance my advocacy for the Less is More Medicine movement. This includes blogging here to share the latest research and opinions, tweeting @LessIsMoreMed to spread the word, participating in related discussion groups (eg. Teaching Value in HealthCare on Google+), and using LinkedIn to connect with colleagues in my province who are also engaged in health care transformation. I also listen to podcasts (like the BS Medicine Podcast) to keep up to date on the latest studies relevant to this area and prescribe YouTube videos (like those of Dr Mike Evans) to patients to help them join me in shared decision-making or to help them self-manage using less harmful and costly measures.
 

Curious about how to use Social Media in your professional existence as a health care provider?

Here is the brief talk I gave to the UBC CPD Practice Survival Skills audience in Vancouver, Jun 13, 2015.

There is also an accompanying handout which highlights some of the key resources that will help guide you to (safely) using HCSM professionally.

The talk and handout present a fairly superficial overview of how one might use social media to advance a clinical or advocacy agenda, but hopefully it gives you a taste of how you might use this technology meaningfully. Or, it might encourage you to not use it at all, which is also a valid choice!

For me, #hcsm has been the foundation for this Less Is More work. It is the means by which I can make a big splash with no budget (other than my own investment of 'spare' time and web hosting fees), grow my expertise (with no advanced degree in health policy), and network with heavy hitters in this field (who I would otherwise be unable to access).

It is an incredibly powerful tool.

Source: https://prezi.com/zqkq47ihjazf/hscm-going-...

PRESENTATION SLIDES: Choosing Wisely (& Beyond): Starting Conversations Around Unnecessary Tests and Procedures

The slides from my UBC CPD 50th Annual Post Graduate Review in Family Medicine talk are now available, here on Prezi.

The handout can be seen here.

Start with the 11 recommendations for family practice physicians/patients from Choosing Wisely Canada, and then 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.


It was a pleasure to share this brief presentation, to hear the great questions and discussions on the subject, and to see how these challenges were highlighted in the other talks of the day. Inappropriate health care (or "too much & too little medicine") is a prevalent issue. Hopefully starting with campaigns like Choosing Wisely and the effort to curate similar projects/conferences/resources with "Less is More in Medicine" provides a good start to tackling this immense issue.

20 minutes is not a long time to explain the problem of "too much medicine," to share what is already being done and to inspire and create a call to action. Fortunately, I have the opportunity to speak at other events including the SRPC's Rural and Remote conference in April in Montreal as well as at the St Paul's Family Medicine course this November in Vancouver.

To find out more about my past and future talks, look at the Media/Talks section.

Source: https://prezi.com/bpguaxve_yyx/ubc-cpd-50t...

Physicians are also squeamish about Advance Care Planning discussions!

The Vancouver Sun featured an article, "Refusal to face reality of death leads to increased use of aggressive, futile health-care efforts: Doctor calls on Canadians to 'normalize conversations' about end-of-life care"

It's great to see this kind of story popping up across the news. The more we talk about it, the less scary it is to discuss; the end result is that we'll provide less futile care and offer better palliation, sooner, meaning that patients can have the best possible quality of life until the end.

The title of the video basically says it all; cardiologist Dr Heather Ross talks about the challenges that physicians face when they need to talk with patients about end of life care. It's interesting that she should remark on her discomfort with these kinds of discussions, as that was not something that came up in the study that prompted this Sun feature. 

The study in JAMA Internal Medicine is Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians. You at al. surveyed 1256 Canadian health care providers to identify some of the major challenges with discussing end of life situations and they identified the following:

  • family members' or patients' difficulty accepting a poor prognosis

  • family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments

  • disagreement among family members about goals of care

  • patients' incapacity to make goals of care decisions

Clinicians did not view system factors as significant barriers to these discussions, which I find surprising since we usually talk about underfunding, overcrowding, paperwork, communication errors, and bureaucracy whenever we have a tough problem to solve.

Interestingly, health care providers did not feel that their own skills presented major barriers to having care planning discussions. Well! I find that hard to believe. Clinician factors probably contribute greatly and we seem to have a blind spot for our own weaknesses!  

Fortunately Dr You acknowledges this:

“Overall, the sense from the clinicians is that patients and families tend to get in the way” of making concrete decisions about a patient’s care plans, You said. “This is what they perceive,” You said. 
“But I think it reflects that if patients and families are having a difficult time, then one of the solutions clearly has to be that physicians need to be skilled communicators — they need to know how to navigate these sometimes emotional or difficult discussions and be sensitive,” he said

A clinician's personal discomfort, uncertainty about prognosis, fear of not being liked, and other individual factors are definitely contributors to the difficulty of talking about dying with patients. A lot of the things that make it hard for doctors and nurses to talk with patients about planning for death and dying also contribute to the more general problem of inappropriateness in health care. 

So what can we do? Start here: It's Time to Talk: Advance Care Planning in BC. 

I'm proud to be a part of the Doctors of BC Council for Health Economics and Policy (CHEP), which is where Dr. David Attwell  spearheaded the creation of this policy paper.

Take a look. It's never too late to start talking about it!

My #FMF2014 talk slides: Less is More in Medicine

My Family Medicine Forum talk slides are now posted here. It's also embedded below.

Other talks will always be posted in the media/talks section.

Thank you to all of you who attended! I would love your feedback - please fill out your evaluations or email me lessismoremedicine@gmail.com

 


Less is More in Healthcare (an evening with Dr Iona Heath)

Speed. Need. Greed.

Dr Iona Heath came to Vancouver, BC to talk about When Less is More in Healthcare, thanks to efforts by many, and particularly Dr Tracy Monk, of British Columbia's Center for Relationship Based Care.

I was humbled by Dr Heath's first slide: A screenshot of my website. That's right. Jaw-dropped, cheeks rosy, I stared at the front page of Less is More Medicine in all its glory on the screen at the front of the room.

And it got much better from there. Dr Heath wove clinical examples with philosophical perspectives to make the case for Less is More in Healthcare. Her essay along similar lines - The Art of Doing Nothing - can be read here.

To us she spoke about the barriers to achieving this kind of care and how or why things wound up as they have. Speed can be a problem in many ways. Rushing to cure and fix everything, we forget the patient and their wishes; an elderly woman goes to the hospital, gets poked and prodded and optimized, and dies two weeks later anyway. How efficient. ?. She would have stayed home and been cared for at home, if given the choice.

In the talk, as in the essay, Dr Heath makes reference to Christopher Rick's book Beckett's Dying Words. His reflections help illustrate the problem of our strange obsession with fighting death at all costs; later, she drew from Beckett himself:

Samuel Beckett understood more about futile doing than most. He is ­de­scribed by the literary critic Christopher Ricks as:

The great writer of an age which has created new possibilities and impossibilities even in the matter of death. Of an age which has dilated longevity, until it is as much a nightmare as a blessing.

In Malone dies, Beckett writes:

And when they cannot swallow any more someone rams a tube down their gullet, or up their rectum, and fills them full of vitaminized pap, so as not to be accused of murder.

(my German is not great but I believe the essay is a transcript from Dr Heath's keynote lecture at The Art & Science of General Practice and Family Medicine)

The most resonating part of the talk for me was the dissection of our persistent and inflated idea of "need."  Dr Heath found many ways to point out the ridiculousness of our quest to create patients, including thoughts from post-war Polish poet Zbigniew Herbert:

I invented a bed with the measurements of a perfect man
I compared the travellers I caught with this bed
It was hard to avoid - I admit - stretching limbs, cutting legs
The patients died, but the more there were who perished
the more I was certain my research was right.
The goal was noble.  Progress requires victims.

However, it was Iona's casual phrases, like "the contemporary distortion of need" that so eloquently stated the issue. By diagnosing "risk," like an increased risk of heart attack or stroke, we inflate the need. We create a responsibility to do something, do anything to prevent a potential thing that hasn't happened yet and might but probably won't.

We have done this in the case of mammography. For years we promoted self-exams and clinician breast exams. Then we realized those were a waste of people's time and encouraged worry about lumps that were nothings. So we said "just mammogram." In 2009 I read the New Zealand guidelines for screening for breast cancer. At that time, they were encouraging against clinician exams and even suggesting that mammography might not be recommended in future. I failed to convince one of my preceptors, a wise and thoughtful guy. For years he had helped women find "the lump" that ultimately was hacked off, irradiated, and chemo'd, and their lives had been saved. Patients, convinced by their doctors for years and years, still feel something must be done. "Early detection is key."

That anecdotal experience is hard to trump, but as the data floods in, we are discovering that less is more. It is the responsibility of physicians and the medical community to undo the messaging that we touted for years.

It never boils down to just randomized controlled trials, NNTs, or confidence intervals. We are caring for humans, and that cannot be reduced to just fighting disease or perceived risk.

Powerful words bear repeating and so we were given some of Annemarie Mol's to chew on.

The Dutch philosopher Annemarie Mol, in her book The Logic of Care, writes about how ‘the logic of choice’ now undermines ‘the logic of care’.  She says:  ‘Even if good care strives after good results, the quality of care cannot be deduced from its results.  Instead, what characterises good care is a calm, persistent but forgiving effort to improve the situation of a patient, or to keep this from deteriorating’.  The richness of that aspiration compared with getting the numbers to the correct point is incredibly important.

Mol goes on:  ‘You do what you can, you try and try again.  You doctor, but you have no control.  And ultimately the result is not glorious:  stories about life with a disease do not end with everybody ‘living happily ever after’.  They end with death.’ Unless we as both a profession and as a society get over the idea of death as medical failure, we are doomed to torture our patients when we should be leaving them alone. (from The International Futures Forums)

Exploring need, the example of the overdiagnosis of ADHD and the medicalization of our children emerged. Dr Heath explained that labeling and medicating children teaches them 'that they are not normal, not responsible for their behaviour, and that answers come in pills.' It might be that our kids are not disordered - they just learn in a different way. See this snippet of Sir Ken Robinson's great Ted Talk on the subject:

Lastly, there is greed. Diseases are invented in order to market drugs. Normal behaviour is medicalized, or deemed pathological as we sterilize the definition of 'normal.' Those who have get more, and just because we can do something expensive and fancy and new doesn't mean we should. Christopher Ricks:

It is now almost impossible to die with dignity in USA unless one is poverty stricken

If you have the means, you'll be poked and prodded beyond your heart's desire. We've got it wrong most of the time. Doing more is not better, and fails to solve the underlying problem. "We seek technical solutions for existential problems" (Overdiagnosis: when good intentions meet vested interests—an essay by Iona Heath) and that leads us down a very slippery slope. Just one more test. Let's try this treatment.

 

Let's stop. Let's think of the patient and what matters to them. Or as the patient, what matters to us? Must we keep our numbers within normal parameters? Shouldn't we just strive to feel good, pursuing a "modified hedonism," in order that we might appreciate more the quality than the quantity of life we are given?

General practitioners would do better to encourage people to lead lives of modified hedonism,so that they may enjoy, in the full, the only life they are likely to have.

(J McCormick, Health promotion: the ethical dimension, Lancet, requires subscription)

 

I admire the strength of Dr Heath. She is an unapologetic champion for the right care, and explained to us with wisdom and compassion the reasons we've wound up in this state of aggressive care, and offered solutions for moving past it. The role of the Family Physician and the connection we share with patients is central to this.