COURSE: Practising Wisely - Reducing Unnecessary Testing and Treatment

When I speak to peers and clinicians, one of the most frequent bits of feedback I receive is "Great! I'm on board with delivering more appropriate care, Choosing Wisely, making sure my patients make shared decisions and avoid unnecessary tests and treatments. But... I don't really know how to 'do' it. Where do I start? How to I talk to patients? Where do I go to practice?"

So, it is with extreme pleasure that I announce the expansion of the Practicing Wisely: Reducing Unnecessary Testing and Treatment Course. Originally "Don't just do something, Stand there!," this highly-regarded hands-on learning experience was started by the Ontario College of Family Physicians and is spearheaded by Dr Jennifer Young.

It is now a suite of continuing professional development opportunities for primary care providers, available in a modular format across the country. In the course: 

Participants will identify opportunities to "practise wisely", with a focus on reducing over-prescribing, over-imaging, over-screening and over-monitoring using the latest evidence and tools from diverse sources. This workshop aligns closely with the Choosing Wisely Canada (CWC) campaign to implement good healthcare stewardship and avoid over-medicalization.

The program centres on case studies and incorporates individual reflection and group work. It helps participants to build communication skills to guide their patients through the shift from seeking sickness to enhancing health.


After active engagement in this program, participants will be better able to:

  • Identify opportunities to reduce “too much medicine”
  • Access and assess reliable, renewing online resources
  • Integrate relevant evidence into individual patient care
  • Communicate and build consensus with patients to reduce over-medicalization

    Upcoming Workshops are taking place as follows:

    May 24/17 - Montreal
    May 29/17 - Ottawa
    June 3/17 - Newfoundland
    Nov 22/17 - Toronto

    Find out more about the Practising Wisely program by viewing the main website or reading through this Q&A with Course Director, Dr. Jennifer Young.

    Source: http://ocfp.on.ca/cpd/practising-wisely

    FACTS & MYTHS: Prevent and Treat Cancer with Diet and Lifestyle

    Families, doctors, nurses, patients, people all:

    Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.

    Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.

    There are things you can do to lower your risks, robustly backed by the evidence: 

    • Avoid smoking
    • Exercise regularly
    • Stay away from environmental/industrial carcinogens like asbestos, radon, and benzene
    • Reduce radiation exposure by avoiding unnecessary medical imaging tests
    • Avoid excesses of alcohol
    • Wear sunscreen
    • Consider a pap test
    • Only take supplemental hormones if medically required
    • Get other 'screening' tests eg. colonscopy if you are a high-risk patient (eg. an immediate relation was diagnosed with colon cancer)

    There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.

    As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.

    Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.

    Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.

    In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:

    • Eating whatever you want
      • to try to slow the process of weight loss from cancer and to enjoy life because food = joy for many
    • Using money to enjoy experiences that are important to you 
      • visiting family, ticking items off the bucket list... one incredible patient I met shocked his family and had an incredible time by skydiving for the first time after age 70 (despite cancer with metastases to bone!)
    • Focusing on treatments that have been shown to be effective through scientific study
      • nothing breaks a caregiver's heart more than seeing someone chose an 'alternative' treatment when there is a validated one that would likely be well tolerated, and is quite likely to lead to cure (eg. death of Makalya Sault, after her family got their hopes ensnared by a quack in Florida
    • Working through the difficult task of coming to terms with having cancer, whether treatable or not
    • Receiving palliative care (which improves quality of life and can actually extend life!)

    Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.

    --

    Learn more about Tackling cancer treatment myths, from clean eating to cannabis

    Source: https://www.theguardian.com/science/blog/2...

    Minimally disruptive medicine: Effective Care that Fits Workshop SEPT 2016

    I read the fantastic Minimally Disruptive Medicine (MDM) Blog and want to bring your attention to the Mayo Clinic KER Unit MDM event, coming soon:

    From the MDM site:

    Click on the image to find out more about the Minimally Disruptive Medicine Workshop.

    Minimally disruptive medicine (MDM) seeks to advance patient goals for health, health care, and life, using effective care programs designed and implemented in a manner that respects the capacity of patients and caregivers and minimizes the burden of treatment – the healthcare footprint – the care program imposes on their lives.

    This site is maintained by researchers at the KER UNIT who are part of an international research team that is working on understanding and implementing MDM across the world.

    Some introductions to MDM:
    From the peer-reviewed press
    From the medical press
    From the lay press
    From Wikipedia
    From a presentation (video) 
    From a radio interview (audio)
    Complexity Care Model article

     


    For more events related to "Less is More," "Choosing Wisely," "Preventing Overdiagnosis," "Shared Decision-Making," etc, go here.

    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...

    Minimally Disruptive Medicine: Thinking differently about nonadherence

    In a follow up to Disutility: Finding the balance between benefit and hassle, I present this video from the North American Primary Care Research Group  (NAPCRG) Annual Meeting.

    The answer to healthcare is education. Nevermind the other aspects of their life, nevermind that they have multiple diseases, side effects of medications, and not enough time in the day to do all the health 'work' that we give them . Teach patients, yell at patients, scare them into doing what you (the doctor) says. And if they don't take responsibility and do it, then... fire them as your patient!

    Or not.

    Dr Victor Montori, champion of Minimally Disruptive Medicine, explains a radical new way to think about "nonadherence" and the work that we give our patients to do.

    NAPCRG Plenary I: Minimally Disruptive Medicine; Victor Montori, MD


    Source: https://www.youtube.com/watch?v=cHSWDMH2rf...