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.

 

How Much Are We Over-Diagnosing Cancer?

The word about 'overdiagnosis' is a regular feature in medical journals, stories are found at least weekly in major newspapers, and patients are starting to question whether cancer screening tests are really right for them.

Victory!

Ok, no no, we are a long way from finding the right balance of too much and too little medicine. But now that we accept that 'too much medicine' is a real thing, we need to figure out just how big the problem is.

Peter Ubel (@peterubel) is a physician and behavioural scientist, and author of Critical Decisions (see this and related books on our list)

He has attempted to lay out the way in which we can quantify (and clarify) the times where we inappropriately give a person the label of 'cancer.'

He states clearly that misdiagnosis, while unfortunate, isn't overdiagnosis. He also says that false-positives, while they can lead to harmful results, are not overdiagnosis.

What is is then? Whole conferences (eg. Preventing Overdiagnosis) have been devoted to defining it. 

Overdiagnosis, according to Ubel, occurs when we detect things that would never have caused a problem for the patient. He gives the example of a tiny breast cancer that would never have been noticeable in an elderly woman (who would undoubtedly die of something else first). When trying to change the culture to encourage people to stay away from screening tests that will lead to overdiagnosis, we are up against several challenges. One of those is the fact that early diagnosis can sometimes make it seem like we live longer if we detect the cancer earlier, though finding it early doesn't improve or save our life (lead-time bias, which is explained in the article).

Ultimately, in order to quantify the prevalence of overdiagnosis, we will need population-level data after a screening program has been introduced, and the data will need to be measured for long enough that any of the lead time bias effect will have passed.

Read more of Dr Ubel's explanation, How Much Are We Over-Diagnosis Cancer? in Forbes.

Source: http://www.forbes.com/sites/peterubel/2015...

Better informed women probably less likely to choose mammography

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An interesting article was published in the latest Lancet: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial.

In brief, women who got information about the risk and possible harms of breast cancer screening (by mammography) were less likely to intend to be screened. The study didn't go on to look at what the women actually chose (only what they intended to choose). However, it still confidently suggests that women who have all of the information are less likely to get screened.

Contrast this informed approach with the classic approach from the well-intentioned doctor: "You need a mammogram to screen for breast cancer. Here is the requisition."

It is not wrong to say no. (These are the words of Dr Iona Heath - well ahead of the curve - in the title of a  BMJ paper in 2009 regarding this same topic).

It is not wrong to say no. And the more you know, the more likely you'll say no. 
 

Not sure what to do for yourself?
Not sure how to start discussing this with patients?
 

- Here is a Canadian resource to help you decide if Mammography is right for you; it's not perfect but it is a start

- Below is an icon array from the Harding Center for Risk Literacy that helps visually represent the benefits vs. harms of mammography:


Source: http://www.thelancet.com/journals/lancet/a...

The Preventative Visit and Choosing Wisely

The preventive health visit is not synonymous with an 'annual physical'

I always felt lost when asked to do a general exam on a healthy person. Every physician performed it differently. Do we check for breast masses? Feel the thyroid? Look at the tongue and mouth for squamous cell carcinomas? Check the belly for a pulsatile mass? Listen for a murmur? Heck it would take hours to go over every mole and mucosa, to palpate every bump and move each joint. So what were we doing?

The American Choosing Wisely campaign, in the list of Society of General Internal Medicine suggestions, recommended in 2013 that physicians stop “performing routine general health checks for asymptomatic adults." (see some backing data)

Many were outraged by this, and a similar decision in Ontario by the provincial government to de-list the annual physical exam, such that physicians would no longer be paid to provide this service to patients who don't require it. The concern was mainly that very important preventative health and screening measures would no longer be undertaken.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

But, a preventative health visit is not the same thing as an annual physical. For example, we've got decent evidence that pap tests are important screening tools for cervical cancer, and have changed our guidelines to use them less frequently. And we are not suggesting dispensing with this. However, recent studies have shown that the pelvic exam (feeling the uterus and ovaries, essentially) really is not essential and many organizations are beginning to recommend against this practice. We had been doing pelvic exams out of "tradition" for the longest time - how much else is driven by tradition?

I come back time and time again to the Milstein paper from Health Affairs, Why Behavioral And Environmental Interventions Are Needed To Improve Health At Lower Cost. We know that prevention is key, but we don't know how, when, or where to deliver it. Dispensing lifestyle advice in the office probably doesn't work (eg. GP advice is ineffective in improving metabolic outcomes in high risk patients). Clearly we need something different to achieve a persuasive, meaningful impact.

A colleague recently sent me an article, from the American Journal of Preventative Medicine (access required - ePub ahead of print, Jul 2014),  which addresses concerns with the way our push for efficiency and appropriateness may be drawing attention away from the real issue of prevention. Wong, Gaster, and Dugdale write:

. . . the Choosing Wisely Campaign sends the wrong message at a time when prevention remains more important than ever, and as the data supporting it grow more complex and more nuanced. The preventive health visit has and will continue to evolve . . . The preventive health visit currently remains an effective tool for increasing adherence to evidence-based service guidelines. This is no time for us to abandon it.

I would personally need to learn a lot more about what "effective" is meant to construe in the above sentences before agreeing wholeheartedly. I don't disagree that we need to spend a lot more effort looking at prevention, but I don't think Choosing Wisely contravenes that effort. 

 

What do you think?

Simple tool illustrates risks/benefits of prostate cancer screening

Struggling with what to do as far as prostate cancer screening?

The Harding Center for Risk Literacy has some very helpful illustrative "Fact Boxes" that share the evidence behind Digital Rectal Exams (DREs) and Prostate Specific Antigen (PSA) tests.

See the "Risks and benefits of prostate cancer screening" on their site.

Of course, these shared decision-making (SDM) aids only take into account the Cochrane Review, but this is a systematic meta-analysis and so I think quite powerful data.

To see a bit more background, but a similar conclusion, view this review in the Journal of Family Practice. They suggest:

Do not routinely screen all men over the age of 50 for prostate cancer with the prostate-specific antigen (PSA) test. Consider screening men younger than 75 with no cardiovascular or cancer risk factors—the only patient population for whom PSA testing appears to provide even a small benefit.

Family medicine literature seems to be consistent with the above, though our practice lags behind. Many of my urologist colleagues shake their head and insist that we offer screening PSAs, but I'm beginning to feel it just doesn't add up to "good care."


What do you think? Would you get screened? Would you encourage your patients to be screened?

If you are looking for more decision-making aids, check out the Hands On part of the Tools section on this site.

Study: Many Invasive Medical Procedures are the Result of Uncertainty, Not Evidence

Forbes contributor David DiSalvo offers reflection on a JAMA article which highlights the epidemic of overtesting and delves into the origins of this behaviour. 

“The psychological dynamic of investigation momentum has two major parts,” Dr. Sah explained during a phone interview. “The first is our inherent aversion to ambiguity. The second is the sense of commitment we feel once we’ve started an investigation and feel like we must continue.” . . . 

these results tell us is that of all the testing variables, uncertainty was the biggest catalyst moving participants toward choosing an invasive procedure . . . As Dr. Sah explains, the implications of these results do not only reflect on patients. “Physicians also want to resolve uncertainty.  It is peoples’ tendency toward wanting to resolve ambiguity overall–both on the parts of patients and doctors–that fuels investigation momentum.”

The JAMA paper and the interview responses from Dr Sah are illuminating. If we can understand why we perpetuate our tendency to overinvestigate, perhaps we can intervene more fruitfully.

Read more on Forbes.

Seven key health trends for 2013

Science-ish wrote about some of their top predicted trends for 2013 including two (or three) that are relevant to "Less is More" in Medicine:

5. Shifting screening mores: 

The cancer screening debates heated up again in 2012. The scientific community now recommends against routine PSA testing for prostate cancer in men, and that for women, while diagnostic mammography can be helpful, mass screening is not as effective as was once believed. As more robust evidence emerges and guidelines shift, expect to hear more about the public-health challenge of communicating shifting mores to patients . . .

6. Slow medicine: 

. . . the world must wake up and realize “medicine is far from being an exact science” and what we need now is more “slow medicine”—thoughtful, considered and evidence-informed. . .

7. Evidence revival: 

Science-ish has argued that the ideals of evidence-based medicine must spread beyond the medicine cabinet and bedside. . . Though striking the right balance among values, politics and science is no easy task, when there are fewer resources, there will be less space for policies that don’t work . . .

Read more at Science-ish.