The Case for Being a Medical Conservative

Drs Vinay Prasad, John Madrola, Adam Cifu, and Andrew Foy have written a fantastic article about what they call “Medical Conservatism.” Read it HERE

I never thought that those in the movement to prevent overdiagnosis/medicalization and overtreatment would be labeled as “conservative” in our thinking - but I identify directly with many aspect of this article.

I am proud to work with an organization (The Therapeutics Initiative) which does rigorous, unconflicted review of the medical evidence. Many (but not all ) of our conclusions are essentially that the drugs don’t work as well as we wish they did. And for coming to these conclusions, we have been called nihilists.

Like anyone, I want the medications to work, and work well. Yet, I understand that they often do not, and that we need to stop pretending that they might kinda sorta a little, when the evidence says that they (sadly) really don’t make a meaningful different for outcomes that matter to patients. This can be hard to reconcile in clinical practice where clinicians and patients alike get stuck on the hope of success in the face of illness and adversity.

The authors explain there terminology further:

Our choice of the term medical conservative does not imply a political philosophy, although William Buckley Jr.'s definition of conservatism aligns well with our approach to patient care:

“A conservative is someone who stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it.1

Here is what we believe:

Medical conservatives are not nihilists. We appreciate progress and laud scientific gains that have transformed once deadly diseases, such as AIDS and many forms of cancer, into manageable chronic conditions. And in public health, we recognize that reducing exposure to tobacco smoke and removal of trans-fats from the food supply have contributed to the secular decline in cardiac event rates.2 Indeed, medical science has made this era a great time to live.

The medical conservative, however, recognizes that many developments promoted as medical advances offer, at best, marginal benefits. We do not ignore value. . . . The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased. 

In the article, they show this graph, comparing the magnitude of benefit for a patient to the cost of the care, with some examples:

gr1_lrg.jpg

The area on the left is where we want to be. The “A” items make a really really big differnce for people’s well being. Not surprisingly, a lot of the modifiable social determinants of health live in “A” territory. The trouble is the “C” territory, the things that we do that make basically no impact for patients but that cost an extraordinary amount in terms of harms, burden, and financial measures for patients and society.

My colleague Juan Gérvas said it well when he wrote our ‘preventing overdiagnosis’ mailing list: “the end of the curve is not flat, but going down... [at that point, the] harms outweigh benefits.; on the end of the flat part of the curve, additional spending, whether it be on a new drug, device or diagnostic test, confers more harms than benefits to individual patients or society".

CONFERENCE: Hellish Decisions in Healthcare Jan 2017

Hellish Decisions in Healthcare is designed as a space for healthcare leaders, professionals and researchers within the international healthcare community to shape healthcare policy and systems to deliver Triple Value.

  • Personalised value, the delivery of services informed by what matters to the individual

  • Technical value, determined by how well resources are used within services for each purpose

  • Allocative value, determined by how the assets are allocated to services for different purposes.

The decisions and strategies needed to deliver Triple Value will not always be immediately apparent and nor will they be easy to make; the Value in Healthcare Forum is a safe place where these strategies can be developed and where strategic discussions can be had with the key thought and implementation leaders in healthcare.

Read more on the website and do Register by Oct 15 for the Early-Bird Discount.  The event will be in Oxford, Jan 12 to 13th, 2017.


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

 

Source: https://www.phc.ox.ac.uk/events/hellish-de...

Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals | National Post

In our disposable culture, it is unsurprising that the bleed of this trend into healthcare has gone largely unchecked.

Operating rooms now use scads of throwaway equipment, saving sterilizing time and shaving off some intra-operative minutes by using devices that are slightly more specialized for components of the procedure.

Surgeons, nurses, and patients are all unaware of the cost. In fact, "Surgical residents and staff have a generally poor knowledge of the cost of common consumable products used in the operating room," according to a recent study in Laryngoscope by Canadian otolaryngologists.

Tom Blackwell of the National Post highlighted the issue and discovered some of the simple changes that administrators and surgeons could make to save costs without significantly impacting operation times. These efforts would also reduce landfill waste, something not emphasized in the article, but a very important consideration for the long term sustainability of our health care system.

See the video and article: Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals.



Source: http://news.nationalpost.com/news/canada/s...

Day 1 of Road to Right Care #Lown2015 Recap

What a great day!

Hundreds of mainly American (I am one of 4 Canadians here) doctors, patients, nurses, health administrators, and other health providers gathered today for the first of three days on the Road to Right Care Conference, put on by the Lown Institute.

Being in a room with so many like-minded individuals is invigorating but also offers hope that together, we can actually do something radical.

Main Themes:

  1. Patients and their families and advocates must be at the centre of this movement; young health care providers are the future of this and must be engaged early in their training
  2. Health care is not about consuming, being sick; most of what we do in medicine has no impact on health; health care should be about being well, and about people not diseases:
    “A good physician treats the disease, the great physician treats the patient who has the disease.”  - DR. WILLIAM OSLER

  3. Social determinants of health, especially poverty must be addressed for greatest impact:
     "I can cure homelessness. You just house them and it's cured. Completely curable problem." - DR. MITCHELL KATZ

  4. Our system must be radically transformed; we have many ideas but they boil down to the fact that HIGER QUALITY CARE leads to LOWER COST

  5. Barriers to improvement: financial conflicts of interest, profit-based systems, not listening to what patients really want (eg. independence)

  6. Things that will help us achieve RightCare: team work, communication, destroying the imbalance of power, narratives

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

My actions as a result of today:

What was missing?

  1. Emphasis on relationships between patient and caregiver. The ONLY big mention about meaningful relationships was by a Reverend B. Stanfield during his reflection at the end; the data tell us that strong relationship = better care, and less costly care
  2. Focus on patient safety. Americans talk A LOT about cost! Cost is important, but were this conference anywhere else in the world, the main focus would be on reducing harms done to patients by too much or too little medicine.
  3. Acknowledgement of this as a world-wide cultural issue. There was a lot of discussion about insurance companies, ways of paying physicians, etc. as if these financial structure problems all explain the issue; some people seemed to believe that changing the way doctors are paid – abandoning fee-for service payments – would fix everything. But, there is no system of remuneration that incentivizes good care. "Wrong care" is a problem around the world, even in socially progressive and fully public health systems. 
     

I can't wait to see what is in store for us tomorrow!

Perspective: Want to learn the value of healthcare? Try to diagnose your own mother

Dr Ranjana Srivastava is a specialist. Specifically, she is an oncologist (cancer doctor).

Naturally, she thought the worst when her mother became ill and started thinking up a series of diagnoses, implications, tests, and treatments. She struggled a little to decide how much would be important and good advocacy for her mom, and how much was "too much" and might do more harm than good.

Her husband, a GP, interrupted and helped Dr. Srivastava's mother decide what to do next - and in doing so, also answered Dr. Srivastava's bigger question:

Why is it so hard to see the value of experienced GPs?

Read the full article in the Guardian to understand her answer.

Source: http://www.theguardian.com/commentisfree/2...

How residency programs are training doctors to waste money - Vox

It makes sense that our practice patterns are very much influenced by where and with whom we train. Why should there be any exception when it comes to over-ordering tests and treatments?

A recent study in JAMA, Spending Patterns in Region of Residency Training and Subsequent Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries, shows that where we train has implications for high-value care.

Residents who train in regions with high health care costs (that is, the places that err on the side of more scans and specialists) continue to practice expensive medicine decades beyond graduation — even if they move to low-cost parts of the country.
The JAMA paper suggests a tantalizingly easy way to save money in American health care: train more residents in low-cost areas of the country. They would learn, from the get-go, to be more frugal physicians. If there was a way for the health care system to cut 7 percent of all spending just by training doctors differently, after all, you'd think we'd jump at it.
But, like most things in health policy, this is easier said than done.

Read more on Vox.