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...

Mammogram Theater: A Visual Aid For Medical Decision-Making

With a title like "mammogram theatre" you would wonder if this post is meant to poke fun at the elaborate song and dance of mammography; we have spent years promising women that "early detection is key," only to realize that screening mammography cannot do what we originally hoped it could (but many still pretend it can).

Of course women want their breasts and lives saved. But the information on the benefits of mammography has been largely overstated in part due to cognitive biases (like lead-time bias, base-rate fallacy, etc), and the risks are too often left out of the conversation.

Every test has risk and benefits, but it can be challenging to decide if a test or treatment is right for you or your patient when there is too much information, experts disagree when they review the same studies, and the media has a constant see-saw back and forth of "yes" and "no" headlines that seem only to confuse. It can feel a bit like ping-pong, following the discussion back and forth. It's not really fair to ask patients to make sense of all this.

So yes, the promise of benefit of mammography may have been a bit of dramatization, but the theatre I speak of is a literal one. 

Dr. Andrew Lazris is an American internist who partnered with environmental scientist Erik Rifkin to popularize a simple, easy way of showing how many are helped and harmed by common tests and procedures.

Lazris and Rifkin have developed a tool to give people a realistic way of evaluating 'hope and worry;'

Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. (read more on NPR)

This is a tool to help doctors and patients have informed discussions about the risks and benefits of breast cancer screening with mammography, to engage in shared-decision making on the topic. Take a look:

This tool has been added to the "hands-on tools" section of this website, where you can find other tools like it.

Source: http://www.npr.org/sections/health-shots/2...

New Choosing Wisely toolkit with patient handouts - Family Medicine, CFPC

The College of Family Physicians of Canada (CFPC) and its Patient Education Committee (PEC) are pleased to release a new Choosing Wisely Canada™ (CWC) toolkit. This innovative initiative is aimed at educating the public about anticipated changes in how family physicians approach health care prevention.  

Building on the success of the CWC campaign, the CFPC launched a whiteboard video titled Do More Screening Tests Lead to Better Health? This video was developed by the Dr. Mike Evans Lab group and focuses on a number of common screening tests: vitamin D malabsorption, mammography, thyroid testing, chest X-ray and electrocardiograms, Pap smears, dual-energy X-ray absorptiometry (DEXA), and annual physical exams.

The new CWC toolkit provides the following resources: 

Please see www.cfpc.ca/ChoosingWisely for more information, and if you want to see patient handouts and shared decision-making tools from other sources, check out the Less is More Hands On Tools page.

 

End of Guidelines (Video parody by James McCormack feat. ZDoggMD + friends)

James McCormack (@medmyths, BS Medicine Podcast) does it again!

Clinical Practice Guidelines must change! This is the end of guidelines as we know them.

Yes that is me and Gilbert Welch on the same screen. For realz!

Yes that is me and Gilbert Welch on the same screen. For realz!

We need patient centred care, including discussion of the values of the patient, the harms of intervention, and alternative options. Right now we have a bunch of arbitrary target numbers for treatment that medicalize normal people. These guidelines are mired in conflict of interest as the majority of guideline-authors having egregious conflicts of interest with industry. 

It's time to fix this! I'm honoured to be a part of this effort and call for action. It was awesome fuel for my imposter syndrome being asked to be in one of James' videos alongside some of my 'preventing overdiagnosis' heroes, not to mention ZDoggMD (whose videos I have followed for ages, probably since Hard Doc Life). The video features such like-minded pals including but not limited to: Gilbert Welch, Tim Caulfield, Iona Heath, Victor Montori, Richard Lehman and yep, yours truly - "it's just common sense!"

See for yourself and share widely:

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

VIDEO: Take Back Health: Join the #RightCare Alliance

Although the USA is a slightly different animal, with more emphasis on health care as a for-profit industry, many of the same problems exist in Canada and other nations with a primarily single-payer, public system.

The solution to health care interventions that are unnecessary, unwanted, or even harmful is: a social movement. That's what the Lown Institute thinks, and the Right Care Alliance is gaining momentum.

Watch this:

Source: https://www.youtube.com/watch?v=mdeH1bwYYD...

VIDEO: Do More Screening Tests Lead to Better Health? @docmikeevans

Many of you will be familiar with the hilarious and helpful work of Dr Mike Evans and his team. Their white board videos are a great blend of up-to-date evidence, patient perspective, and useful advice.

In Do More Screening Tests Lead to Better Health? you'll find more than just the answer to that question ("No.").

With a focus on healthy, well-feeling, average risk individuals, the video emphasizes that the harms of doing a test (and the sequelae of that test) may be greater than the benefit. This is a tough bit of information to accept particularly if you've already had lots of 'preventative tests' done and have felt reassured by them. However, it's really time to re-evalute their usefulness.

It's not that we should do nothing to prevent disease; instead of wasting a person's time and resources on unnecessary tests, the time can be better spent devoted to support around lifestyle choices that we know will lead to better health. Take a look:

Source: https://www.youtube.com/watch?v=8c7qTsVVxX...

VIDEO: Wasted: Waste and Harm and Unnecessary Tests (Four Corners)

In just 45 minutes, the problem of overdiagnosis, overtesting, and overtreatment is clearly summarized using examples from the Australian system. The costs and harms to patients are incredible, and an analogy – taking the wrong train and winding up where you never intended – is an effective illustration of the issues.

Some key messages:

Billions of dollars are spent on procedures that are not needed, simply because patients expect them and because doctors continue to lobby to be paid to do their 'favourite' procedures.

What is your estimate of how many of those knee arthroscopies are unnecessary? - Dr Normal Swann, Interviewer
Uh, I would say, at least half. - Dr. Ian Harris, orthopedic surgeon

This is no surprise. Dr James Rickert has been advocating for more appropriate care in orthopaedics, for example with an alternative Choosing Wisely list  (despite what the article says, not just 'one guy's opinion' but rather a summary based on the best available evidence, presented most recently at Preventing Overdiagnosis), for years. But conflict of interest, particularly in industry lobbying and influence in the creation of guidelines, continues to be a problem. So does fee-for-service payment systems which encourage higher throughput rather than best care. 

There are other pressures too:

Often the best medicine is no medicine at all, or the best intervention is no intervention at all. But those conversations with patients that take that time to explain that the evidence simply doesn't support doing a test or prescribing a drug  - are long conversations and it's much easier in clinical practice to do things quickly and prescribe or order a test. - Dr Rachelle Buchbinder, rheumatologist

 

Patients and physicians are both uncomfortable with uncertainty, so tests 'just to see,' continue to be ordered, despite the evidence that they are needless and carry risks. We need to realign expectations, save the waste, and re-direct it into areas of health care that will really help people instead of harming them.

Watch the video for more cutting commentary and alarming statistics.

 

FULL VIDEO: FOUR CORNERS: WASTED

TEASER: 


Source: http://www.abc.net.au/4corners/stories/201...

MUST WATCH: Ain't the Way to Die (@ZDoggMD)

Watch this. Share this.

ZDoggMD (Dr Zubin Damania), once a hospitalist, now a primary care revolutionary with his Turntable Health project, has always made hilarious videos about life as a physician, the patients we see, and the culture of medicine.

Below is his most poignant piece, revealing the difficulties of end-of-life conversations and medical futility both from the patient and the physician perspective. It's not corny or cheesy. It is bang-on.

"Ain't the Way to Die" (a parody of Love the Way You Lie, by Eminem and Rihanna) is so scarily accurate. The same problems he sings about are what I wrote about in "I QUIT! Will the law force us to provide futile, harmful care?"

I have not quit medicine, probably because there are people out there like Dr Damania who understand exactly what it's like to be asked to prolong someone's suffering.

I've never been able to relate to the angst expressed in a rap before, I guess because I don't have a lot of angst. But this video takes the words right out of my mouth, highlights all the heavy-sigh moments of these conversations - it's time to call the family, the relative in another country who says "he'll wake up," or the conflict in the family between ones who know he would not want to be a vegetable and the others who are holding on out of guilt or fear.


The vent-bucking sounds and monitor bleeps incorporated into the end of the song squeeze the adrenals.

Do watch. 

4 minutes could not be better spent.

Lyrics: “Ain’t The Way To Die”

Based on “Love The Way You Lie” by Eminem and Rihanna

Just gonna stand there and watch me burn
End of life and all my wishes go unheard
They just prolong me and don’t ask why
It’s not right because this ain’t the way to die, ain’t the way to die

Patient:
I can’t tell you what I really want
You can only guess what it feels like
And right now it’s a steel knife in my windpipe
I can’t breathe but ya still fight ‘cause ya can fight
Long as the wrong’s done right—protocol’s tight
High off of drugs, try to sedate
I’m like a pincushion, I hate it, the more I suffer
I suffocate
And right before I’m about to die, you resuscitate me
You think you’ve saved me, and I hate it, wait…
Let me go, I’m leaving you—no I ain’t
Tube is out, you put it right back, here we go again
It’s so insane, ’cause though you think it’s good, I’m so in pain
I’m more machine than man now, I’m Anakin
But no advanced directive, I feel so ashamed
And, crap, who’s that nurse? I don’t even know her name
You lay hands on me, to prolong my life again
I guess you must think that this is livin’…
Just gonna stand there and watch me burn
End of life and all my wishes go unheard
They just prolong me and don’t ask why
It’s my right to choose the way that I should die

Doctor:
You ever love somebody so much, you can barely see when you with ‘em
That they, lay sick and dying but you just don’t wanna let ‘em
Be at peace cause you miss ‘em already and they ain’t gone
Beep beep, the ventilator alarms
I swore I’d never harm ‘em, never do nothing to hurt ‘em
Hippocratic oath primum non nocere now I’m forced just to torture ‘em
They push full code, no one knows what his wishes were
His sister heard him say once, “I don’t wanna be a vegetable”
But no one agrees in the family, his caregiver Kate
Wants him comfort care but Aunt Claire lives so far away
That her guilt eats her like cancer
So she answers, “Wait! I think he’ll wake”
Maam, you ain’t even in the state!
Palliate, relieve pain, get him home, explain
Critical care? Just hypocritical when it’s so insane
But they insist I shock his heart again so I persist
Guess that’s why they say that love is pain.
Just gonna stand there and watch me burn
End of life and all my wishes go unheard
They just prolong me and don’t ask why
It’s my right to choose the way that I should die
The way that I should die


Source: http://zdoggmd.com/aint-the-way-to-die/

VIDEO: Good Stewardship / Model conversations with patients about overtesting and overtreatment

The National Physician Alliance (NPA) has done a lot of work in the area of preventing overdiagnosis and empowering patients to find the right amount of care. They are a partner in the Tandem Health project/app, created Top 5 lists (in good stewardship) which served as a model for the Choosing Wisely Campaign, and promote responsible prescribing (by limiting influence of the pharmaceutical industru) through The Unbranded Doctor.

Created in 2011, this video is a timeless tool for Good Stewardship. It gives a simple, 5-step plan of how health care providers can discuss unnecessary tests and treatments with patients.

They suggest:

1. Clarify what the patient’s true concerns are
2. Provide the patient with the information he/she needs to understand the plan
3. Be courteous and respectful
4. Provide clear contingency plan
5. Make sure the patient is satisfied with the plan
Source: https://www.youtube.com/watch?v=kh7EKP9wSg...

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