QUIZ: How well do you think about risk and uncertainty?

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Understanding the risks and benefits of all options is critical for effective decision-making. Those who are comfortable with uncertainty and who understand the magnitude of risks tend to excel with decision-making in health, finance, and other high-stakes fields.  By taking the time to consider a problem and engage in self-reflection, more sound decisions can be taken - but a foundation that includes statistical literacy is also required.

The very basic understanding of risk and uncertainty apparently leads you to become more reflective about the information you consume, creating a more rational and informed worldview. In technical terms, it seems to increase your “metacognition” – your capacity to question your own reasoning and judgements.
— Predicting biases in very highly educated samples: Numeracy and metacognition - http://journal.sjdm.org/13/13919/jdm13919.pdf

Many of my peers in the overdiagnosis community are professionally skeptical. These patients, clinicians, and researchers tend to ask questions like: "is that really what the data show?" "how do we know this?" "through what lens was this interpreted, are there any biases?" It is because of this type of reflection that they can distance themselves from the evidence and view it critically. It is not surprising, given our interests, that members of our community score highly on the Berlin Numeracy Test.

Curious about your performance? Test your risk literacy now.

Read the original BBC Article:  How well do you think about risk and uncertainty? for more.

While historically health care providers and administrators have been preoccupied with people underestimating risk, there are profound implications of low statistical numeracy and risk literacy for overtesting/treatment and diagnosis.

These skills are of even greater importance today. “Nowadays patients are expected to make decisions, and they are given much more information than in the past,” [Valerie Reyna] says. You might be given more data about the side effects of different drugs, for instance, when choosing a treatment option – a little like the example question above. Or imagine you have taken a test that reveals a genetic predisposition to certain kinds of cancer. Misinterpreting the risk could lead you to needlessly undergo surgery. “We want patients to be empowered to make decisions – but now that means the burden is on them to understand a lot more technical information, so that makes it particularly important that they are numerate and literate.

Should we enhance risk evaluation and statistical skills education in high schools? What differences would we see in our society if the majority of people had an increased capacity to question their own reasoning and judgements?

Source: http://www.bbc.com/future/story/20180814-h...

Top POEMs of 2017 Consistent with Principles of the Choosing Wisely Campaign

Dr Roland Grad is back again with another persuasive publication regarding POEMs that align with principles of the Choosing Wisely campaign.

I find that infoPOEMs are a quick way to learn about new developments in practice and many of the topics align well with my interest in avoiding unnecessary and harmful care. Drs Grad and Bell have reviewed last year's POEMs with that lens, and their paper offers a great source of input for Choosing Wisely recommendations, as well as a launching point for changing your own practice.

Dr Grad will be presenting the poster at the Preventing Overdiagnosis 2018 conference in Copenhagen.

A POEM is a synopsis of a research study that reports patient-oriented outcomes, such as improvement in symptoms, quality of life, or mortality; is free of important methodologic bias; and recommends a change in practice for many physicians. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for physician-members of the Canadian Medical Association. . . . The recommendations cover musculoskeletal conditions (e.g., avoid arthroscopy for initial treatment of a meniscal tear), respiratory disease (e.g., avoid screening for lung cancer without informing your patient of the risk of a false-positive test result), infections (e.g., do not routinely add trimethoprim/sulfamethoxazole to cephalexin for nonpurulent uncomplicated cellulitis), and cardiovascular disease (e.g., do not prescribe niacin, alone or in combination with a statin, to prevent cardiovascular disease). These POEMs describe interventions whose benefits are not superior to other options, are sometimes more expensive, or put patients at increased risk of harm. Knowing more about these POEMs and their connection with the Choosing Wisely campaign will help clinicians and their patients engage in conversations that are better informed by high-quality evidence.

You can read the full publication here, in AFP.

Previous contribution from Dr Grad and colleagues to this blog can be found here:

 

THESIS: Preventing Overdiagnosis, the Quaternary Prevention

Maria Llargués Pou, a soon-to-be Family Physician in Barcelona, recently shared with me her Bachelor's Thesis. 

Her work - "Primum non nocere" Preventing Overdiagnosis, the Quaternary Prevention provides a concise introduction to the efforts around the world to prevent overuse of tests, treatments, and disease-labels, as well as the reasons we must address this growing issue.

 

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy 

Llargués Pou has beautifully laid out an evolution of ideas, from Ivan Illich's idea of Iatrogenesis, to Jamoulle's attempts to thwart iatrogenic harm with a public health model of Quaternary Prevention, and now, contemporary efforts to tackle overdiagnosis, like the Choosing Wisely Campaign and Preventing Overdiagnosis conference. Her paper serves as a great "backgrounder" for those who wish to learn more about the broad themes and history of this movement.


You can view the full text HERE.

Resource Stewardship Toolkit - for education of resident physicians

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Over the past year, I had the opportunity to contribute to the formation of several toolkits on the topic of "Resource Stewardship." These toolkits were created by the Royal College of Physicians and Surgeons of Canada (RCPSC) in partnership with Choosing Wisely Canada and the College of Family Physicians of Canada (CFPC).

The aim was to create modules that educators could use in order to encourage residents to be mindful of overdiagnosis, overtesting, and overtreating as they prepare for practice. By empowering them to have conversations with patients about unnecessary medical interventions and to undertake Quality Improvement projects in this area, preceptors can ensure that physician trainees satisfy the societal duty (as well as a residency education CanMEDS requirement) to be good stewards.

There are THREE toolkits, each containing a powerpoint and preceptor guide:

  1. Foundations - basic information, vocabulary to facilitate residents becoming mindful of considering the (broad) harms and benefits of any test, treatment, or procedure.
  2. Projects - information and guidance on how to undertake a scholarly (eg. research or QI) project in this area
  3. Communication - scenarios, role play, and other resources to help residents communicate with patients and families who may request an unnecessary test, treatment, or procedure

You can find more education resources on the teaching page.

Source: http://www.royalcollege.ca/rcsite/canmeds/...

PODCAST: Preventing Overdiagnosis 2017 - from theory to practice by BMJ talk medicine

My first Podcast!

Dr Navjoyt Ladher of BMJ talk medicine kindly invited a few colleagues and me to participate in an informal discussion at the Preventing Overdiagnosis 2017 conference in Quebec, Canada.

As working clinicians, we explored moments in our careers that got us interested in tackling overdiagnosis, scratched our heads thinking a little bit about why we (and not all of our colleagues) are taking this on, and reflected on take away messages from the conference.

Have a listen, and go to the original site if you wish to join the discussion.

Source: https://soundcloud.com/bmjpodcasts/prevent...

VIDEO: The Truth about Mammograms - Adam Ruins Everything

Here's a great, brief explainer about the problems with mammography (and most cancer screening)  - 2:43

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Source: http://www.trutv.com/shows/adam-ruins-ever...

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

    A national discussion on unnecessary care #ChoosingWisely #Canada

    I am sharing this in case it has not made the rounds. The Canadian Institute for Health Information (CIHI)/Choosing Wisely Canada (CWC) report, Unnecessary Care in Canada, should be available in April. In the meantime you can read briefly about CIHI's role with CWChere.

    (Original post)


    A National Discussion: Unnecessary Care in Canada

    The Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada (CWC) invite you to join us for a discussion on the extent of unnecessary care in Canada.

    This webinar will introduce a new CIHI/CWC report, Unnecessary Care in Canada, and facilitate a conversation about the magnitude of and variation in unnecessary care across several areas covered by CWC’s recommendations.

    The event will include

    • A moderated panel discussion with:
      • David O’Toole, President and CEO, CIHI;
      • Dr. Wendy Levinson, Chair and Co-Founder, CWC; and
      • Dr. Laurent Marcoux, President-Elect, Canadian Medical Association
    • Speakers from the Canadian Partnership Against Cancer, North York General Hospital and other organizations, who will share their success stories about addressing unnecessary care
    • Q & A session

    Date: April 6, 2017
    Time: 9 to 10:30 a.m. ET

    Please note that this webinar will be conducted in English only and will use Eastern Time. To accommodate multiple time zones, a recorded copy of the webinar will be made available. When you register, please specify if you would like the recorded version.

    Registration: To participate, you must have access to the internet, as well as speakers/headphones. The webinar will be accessible on iOS and Android devices (both mobile phones and tablets).

    To register for the webinar, please email Alison Clement at aclement@cihi.ca

    How do you know? Fact, fiction, alternative truth?

    Humanity has explored many ways of knowing, from trusting deities and their 'earthly conduits,' to seeking out experts, to looking for evidence and statistics, to believing what one feels is 'right.' I am fascinated by epistemology (the investigation of how we know things, of what distinguishes justified belief from opinion) and the psychology of choice, but I am even more interested in what we can do to promote critical thinking.

     

    How do you raise children to question the statements that they hear?

    How do you inspire patients to develop their health literacy and explore how probabilities are presented to them?

    How do you convince policy-makers to consider value rather than throughput in their decision-making?

    Can we convince health 'experts' to include effectiveness, the risks, and costs of various interventions when they write guidelines?

    Apparently the heat from climate change has fried our leader's critical-thinking brain centres, and we now find ourselves awkwardly in an era of supposed "alternative facts." We know that fighting firmly held personal beliefs (even if we consider them lies and delusions) with facts is not effective; however, if you a reading this then you are already probably a bit skeptical, and you can explore the resources below to help with your own decision-making.

     

    HERE ARE A HANDFUL OF PUBLICLY-AVAILABLE TOOLS TO HELP:

     

    1) A book: Know Your Chances - Woloshin, Schwartz, Welch - FREE Online via PubMed

    Every day we are bombarded by television ads, public service announcements, and media reports warning of dire risks to our health and offering solutions to help us lower those risks. But many of these messages are incomplete, misleading, or exaggerated, leaving the average person misinformed and confused. Know Your Chances is a lively, accessible, and carefully researched book that can help consumers sort through this daily barrage by teaching them how to interpret the numbers behind the messages. . . The book's easy-to-understand charts will help ordinary people put their health concerns into perspective.This short, reader-friendly volume will foster communication between patients and doctors and provide the basic critical-thinking skills necessary for navigating today's confusing health landscape.

    [some other books about overtesting, overtreatment, and being skeptical in medicine are listed HERE]


    2) A video: How to spot fake news

    This video highlights the need to be skeptical and question headlines on social media or on other sites; it's sometimes hard to tell if a story is fake. If something seems shocking or strange, it's a good idea to ask around and do a bit of google-sleuthing. Checking the date, the source, and asking a skeptical friend can help you figure it out.
     

    3) A website: Testing Treatments Interactive

    The TTi site contains learning resources to help people recognise and understand Key Concepts, and how use them to evaluate treatment claims. These are categorized by concept, target learning group (kids, undergraduate students, etc), and the format (videos, websites, cartoons, etc). The book is also free and available in audio, PDF, or HTML format.

    4) A guide: 12 Questions to Ask: How to Evaluate Health Information on the Internet

    The National Institutes of Health has put together a great tool to help patients and caregivers check the reliability if information from the internet. These 12 straightforward questions can help you decide if what you are reading is useful - or useless.

    Do you have other tips for getting to the truth? 

    Source: https://www.amazon.ca/Know-Your-Chances-Un...

    A Decision Aid: Goals of Care for Patients with Dementia #SDM

    There was an excellent paper in JAMA Internal Medicine (FULL TEXT), "Effect of the Goals of Care Intervention for Advanced Dementia" that was ePublished in November and is now in print. Dr Laura Hanson, at the University of North Carolina at Chapel Hill, and her colleagues were, in short, exploring the following:

    Question  Can a decision aid intervention about goals of care improve communication, decision-making, and palliative care for patients with advanced dementia?

    Findings  In this randomized trial of 302 nursing home residents with advanced dementia, family decision makers reported better end-of-life communication with clinicians. Clinicians were more likely to address palliative care in treatment plans, use Medical Orders for Scope of Treatment, and less likely to send patients to the hospital.

    Meaning  The goals of care decision aid intervention is effective in improving quality of communication, palliative care treatment plans, and reducing hospitalization rates for nursing home residents with advanced dementia.

    I wrote Dr Hanson who kindly provided a link to their decision aid video. It is 21 minutes, so the best way to use it might be to email it or set up a computer for family members so they can view it when a patient is admitted to a long term care facility.

     

    This video has been added to the Hands On Aids part of the Less is More Medicine site, where you will find lots of other shared decision-making tools.

     

    Hanson LC, Zimmerman S, Song M-K, Lin F-C, Rosemond C, Carey TS, et al. Effect of the Goals of Care Intervention for Advanced Dementia. JAMA Internal Medicine. 2017; 177(1):24-31

     

    Source: https://www.med.unc.edu/pcare/resources/go...