REGISTER: 50th Annual Post Grad. Review in Family Medicine (Vancouver)

Interested in updating your core family practice knowledge?

Want to hear about the Choosing Wisely campaign, or some 'next steps' if you're already an expert? 

I'll be speaking at The University of British Columbia (UBC) Continuing Professional Development (CPD) 50th Annual Post-Graduate review in Family Medicine. I was asked to speak about the Choosing Wisely Canada Campaign and it's an exciting opportunity to share my passion for this and other initiatives within the movement towards appropriateness in care.

As some of the audience may already be familiar with the campaign and using it regularly, I will also offer some "next steps" ideas for these keeners.

My talk, "Choosing Wisely (& Beyond): Starting Conversations Around Unnecessary Tests and Procedures " is at 11:05 on Tuesday, February 25th. To see slides/handouts from my previous talks or to see scheduled upcoming talks, go to the MEDIA/TALKS section of the site.

The Post Graduate Review is a pretty high-yield, practical sort of CME event and knowing some of this year's speakers, I can say I'm really looking forward to talks on Palliative Care, Interesting Cases in Rheumatology, Counselling Anti-Vaccine Parents, Weight Loss in Obesity, and many more! [Sadly I'll miss some of them as my partner's vacation starts on the 26th and we'll be off adventuring, but when it comes to vacation, more is more ;) ]

 

Hope to see you there! (See the brochure and registration form or register online)

Choosing Wisely: Five Things Nurses and Patients Should Question

Nurses are on the frontline of medicine. They know their patients well, support them through every moment of their stay in hospital, and are responsible for a lot of decisions that can help (or harm) patients. 

Since providing high-value and safe care is not just about decisions in the patient-physician encounter, the Choosing Wisely initiative have partnered with The American Academy of Nursing to create a list of 5 things Nurses and Patients should question: 

  1. Don’t automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first.
  2. Don’t let older adults lay in bed or only get up to a chair during their hospital stay.
  3. Don’t use physical restraints with an older hospitalized patients
  4. Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it.
  5. Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.

Read in more detail at Choosing Wisely or see the PDF.

The American Academy of Nursing is not the only non-physician group to have their own list; the American Physical Therapy Association (APTA)  also has a list. In addition, there has been broad collaboration with representatives of the other professional roles in the health care team during the development of The Choosing Wisely campaign.

Many of the society lists were created with the involvement of multidisciplinary teams and patient groups, recognizing the fact that it's going to take engagement at all levels to make a meaningful change that is good for patients and good for our healthcare system.

Projects and Initiatives toward Appropriateness in Medicine: Health Quality Ontario

When I started this website, the ambition was to collect and curate information. So much fantastic research and advocacy has already been undertaken in the area of Appropriateness in medicine, but there was no "one-stop shop" for it.

This growing movement is known by many names, like RightCare, Quaternary Prevention, Overdiagnosis, Appropriateness, Less is More in Medicine, and so on. In Canada, we seem to favour the "Appropriateness in Health Care" phrase.

The field now has so much momentum that it can be hard to keep track of everything. It's a great problem to have when you are passionate about this way of thinking, but as I'm only one person I can miss lots of great things! A friend pointed out a glaring (and wonderful, Canadian) omission:

It is the Health Quality Ontario Appropriateness Initiative, which created a systematic framework for identifying, prioritizing and assessing interventions that are potentially being used inappropriately; they offer evidence reviews and recommendations. Some topics include Measuring HbA1cs in Diabetes and Testing Vitamin B12 Levels in Neuropathy, Alopecia, Dizziness, and Fatigue.

There are many other initiatives, beyond this one and the fairly well-know Choosing Wisely campaign. See the list of PROJECTS for more.

My moral distress: a follow-up regarding forced futile care

Well, I guess I'm not alone.

The article 'Doctors and nurses working with critically ill patients suffer moral distress, research finds' in the Vancouver Sun, unsurprisingly revealed that many health care providers struggle with the kind of care we have to give at the end of life.

Researchers from the University of British Columbia who surveyed 1,400 ICU nurses, doctors and other health professionals have found worrying levels of distress in the very places growing numbers of  Canadians will exit this life. Half the critical care nurses surveyed, and 27 per cent of ICU doctors, said they have considered quitting their jobs because of distress with the way patient care was handled at their hospital . . .

[T]hat waiting time for nursing staff is difficult, because the question in their heads is, is the patient comfortable? Are we actually doing harm versus doing good? Are we prolonging the dying process, rather than prolonging life? . . .

'we’re over-intensifying care at the end of life and causing not only the patient to suffer in those final stages of life, but the poor loved one who witnesses all of this and lives with that poignant memory of an intensified death'

I certainly struggle with this, and it has been the dominant existential angst in my world this past year. 

I wrote about feeling like I would quit my job if I was forced to provide medically futile care. I talked to colleagues, friends, and new acquaintances. I met a woman at a conference in Oxford who said it's something (at the end of her career) that she still struggles with and felt things were getting worse. The one bit of fantastic help I found was a colleague who referred me to the British Medical Association policy "Decisions Relating to Cardiopulmonary Resuscitation"  (Oct 2014), which is perfectly in line with my understanding/beliefs/duty. However, it is not Canadian and so can I really adopt it as my practice? I didn't really feel better. I was worried I'd never enjoy my work again.

I love helping people get back on their feet! There's nothing more rewarding than seeing a spry 87 year old lady racing up the stairs with the physiotherapist after a broken hip recovery! I also feel good when I have brought emotional comfort, relief of pain, a warm smile, a hearty laugh, or helped just by being there for a patient who is dying.

When people die, it is very sad. It is also rewarding to have been trusted to support them as they pass away with dignity and comfort, especially when their life no longer contains the qualities that brought them joy and meaning.

I hemmed and hawed and made plans to work in an environment that would still involve end-of-life-care, but would involve less intense encounters. The affluent, big-city hospital is not the right place for me if I find it morally exhausting to navigate the fine line of catering to patient family's wishes vs "doing the right thing and not causing harm."

We don't want to "give up" on anyone, but maybe that's what it sounds like I am suggesting to my patients? Dr Brett Belchetz suggests that by changing the term from "Do Not Resuscitate" to "Allow Natural Death" ('Do away with the term 'Do Not Resuscitate,' National Post) we can help remove some of the distress around end of life planning. That might help, but there's so much more than semantics involved.

I can't rapidly change the thinking of the people around me, but I can change the people around me! As obnoxious a statement that is, it is true and though running away will not solve this problem, it might help me somewhat. I need more joy back in my days! I get some in the big hospital but I remember having much much more every(any)where else.

My partner and I considered relocating back to Ontario, where we are both originally from, for his job and for me to work in a smaller town. We were convinced Ontario wasn't right for us, with the help of one of his colleagues who had recently made the same consideration. Of course it makes sense for us to stay in British Columbia, but I had mixed feelings about not returning to Ontario. Then, a follow-up article by Tom Blackwell appeared in the National Post: Doctors need patient or family consent before stopping end-of-life treatment: new Ontario draft policy.

Since we are talking about death and dying, let me say this draft policy provided the nail in the coffin on any lingering desires to move to Ontario.

I am again terrified of the precedent this sets. 

The blueprint, to be released officially Thursday, contrasts with the existing advice offered by Ontario’s College of Physicians & Surgeons — that doctors should avoid treatments they believe will be of no benefit or harmful to a gravely ill patient . . .

The current policy says when it is clear that a treatment will almost certainly not benefit or may be harmful to a patient, “physicians should refrain from beginning or maintaining such treatment.”

The new draft says physicians must get consent from the patient, or “substitute decision maker” if the patient is unable to voice his or her wishes.

How can I reconcile my profound moral distress with this policy? How will you manage?

Video: Emergency departments are for one thing only . . .

A really important part of appropriateness in medicine involves making sure patients get the right kind of care in the right setting, by the right provider.

For a laugh (on this serious subject) check out this new video from Queensland, Australia about proper use of Emergency Departments. [Feel free to share with patients]



BCMJ: Measuring and improving quality of care in family practice

With about 400 articles on the subject of "Less is More" overdiagnosis, overtesting, overtreatment, undertreatment, etc. in my Instapaper queue, I figured I should start tackling them again with brief précis or reflective posts so that you can have the benefit of my curating.

I'll probably alternate between older foundational articles and new interesting stuff.

Today: a new article in the British Columbia Medical Journal (BCMJ) by Dr. Martin Dawes, head of Family Practice at UBC, my alma mater.

Quality assurance for family practice should be determined locally and provincially, with a distributed model of quality assurance for the province rather than a centralized model, to increase the likelihood of positive change in response to variations in practice.

Dr Dawes captures it well when he writes of the need for a quality measurement system which takes into account appropriate variations in practice, and that such a system must flex and be  adjusted as we understand more about the meaning of the data we are collecting.

I was glad to see that Dr Dawes, unlike many others, doesn't put all the weight solely on achieving  "targets." It's not that guidelines and clinical measures should be forgotten about, however they are but one part of the larger quality picture and fortunately he spells this out. I worry that governments and health authorities have not yet arrived at this way of thinking.

While I appreciate that things like accessibility are mentioned in the article, I do note the lack of emphasis on (or even mention of) the role of a strong relationship or attachment between doctor and patient in high quality care. Hopefully this is something that decision-makers are well-aware of, and they take it so for granted that they don't explicitly mention it in their articles.  :P

This article is a timely piece as physician organizations, health authorities, and governments in Canada begin the discussion about 'what is good care?', 'how can we measure it?', and 'what can we do to make it better?'

Read more in the BCMJ.

Source: http://bcmj.org/premise/measuring-and-impr...

Dr. Danielle Martin on Transforming Health Care: Three Big Ideas

In 2006, Dr Danielle Martin founded Canadian Doctors for Medicare, an organization which seeks to "provide a voice for Canadian doctors who want to strengthen and improve Canada's universal publicly-funded health care system" and advocates for "innovations in treatment and prevention services that are evidence-based and improve access, quality, equity and sustainability."

Dr. Martin's gave a keynote address at the Family Medicine Forum last week in Quebec and as I was at a CMA Healthcare Transformation Working Group meeting, I was unable to attend.

However, even those who weren't there we aware of the profound importance of her talk. She presented Three Big Ideas for transforming the Canadian Healthcare System. They are sensible, explicitly involve "Less is More Medicine," and are achievable.

She's also speaking on this topic in Vancouver on November 27th.

If you cannot attend one of her talks in person but want to know what her Three Big Ideas are, you still can. Fortunately, she was also the inaugural speaker for the Now or Never: Innovation in Health Care Forum series in Halifax and this was recorded, so you can view a similar talk in its entirety below:

I must admit, Dr Martin already had me won over long ago but her no-nonsense approach to defending, nay, promoting medicare solidified it. Her pointed responses to American politicians this spring had me howling with laughter (and cheering in agreement).

Watch the whole thing or just 2:55-4:00 of the video below if you want to see the bit where her education and passion allow her to shut down the opponents completely. *high five*

I think the Canadian Health Care system is in good hands with her vision.

My #FMF2014 talk slides: Less is More in Medicine

My Family Medicine Forum talk slides are now posted here. It's also embedded below.

Other talks will always be posted in the media/talks section.

Thank you to all of you who attended! I would love your feedback - please fill out your evaluations or email me lessismoremedicine@gmail.com

 


I QUIT! Will the law force us to provide futile, harmful care?

My partner, Ian, is a pilot. Sometimes he has to get up very early, and one day this week I woke up with him and his alarm at 4:00AM.

While he got ready for work, I flipped through the news on my phone. When I found this story by Tom Blackwell, a health care reporter with the National Post, I lay in bed stunned, unable to fall asleep again.

Toronto hospital illegally imposed ‘do-not-resuscitate’ order against wishes of dying man’s family: medical board (Read)

I was not stunned to read that doctors deemed it inappropriate to offer resuscitation, intubation, and ICU-level care to an 88 year old man who had multiple significant medical problems, including recent bilateral leg amputation. The average patient over 85 has a ~4.5% chance of "good outcome" (leaving the hospital neurologically intact) after resuscitation and I expect this man's chance would have been much lower given the vascular implications of bilateral leg amputation (Good Outcome Following Attempted Resuscitation).

The story mentioned that the doctors unilaterally imposed the DNR order. To read that they switched from DNR to FULL CODE at the family's request is testament to the pressure they must have felt. When they switched it back, it sounds like they did not inform the patient's family of the change, which I think is unfair. However, refusing to provide medically futile care is something that doctors need to be able to do.

I am terrified of the precedent set by the decision of the Health Professions Appeal and Review Board.

Ian, tying his tie, was not surprised at my dismay. I told him I'd have to quit medicine if providing harmful and futile treatments became the law in my jurisdiction.

I can't do it. I just can't.

He looked at me, empathetically. He often tells me that if he took his work home, it would be a bad day for everyone. Plus, commercial aircraft are not allowed in our on-street parking area.

He knows my work is with me all the time. My heart aches far too often these days, as I wonder how long I can last in my job a large, big-city academic hospital where we face demands for unnecessary and sometimes harmful intervention regularly.

These discussions are usually different when undertaken in a rural setting. I've worked in Nunavut, where many people still hunt for the majority of their food, and patients and families seem to understand death. It is not that death is welcome, but there is an understanding that life on Earth will end. When a dying patient tells me their fear of losing dignity and of being in pain, I can reassure them, I can ease their physical pain and support them emotionally for their remaining time. I feel that I am needed as their doctor, and they trust me to help them in any way I can.

Lately, at the big city hospital, colleagues and I have been dealing with families that are adamant we provide what we consider futile and inappropriate care. This is medical care that physicians believe is not helpful and may even be harmful to a patient.

We all want to look after the patients as best we can. We want to be seen as good at our jobs and we want to be liked but above all, we want to do the right thing.

We talk about it at lunch. We wake up in the middle of the night worrying about it. I know this because I asked a colleague if I was the only one, and he told me that he had been up the previous night, worrying about what to do! The oath we swore tells us "Above all, do no harm" and yet we are constantly being asked to prolong suffering. It is distressing. How can we so flagrantly violate our ethical responsibilities?

 

Each person holds has varying definitions of "suffering." So, we talk about these cases, nurses give us their thoughts, and we get multiple physicians including specialists involved to bring new perspective. Sometimes there's an ethicist brought in to help. Most of the time, all the professionals agree.

However, no matter what we say, we cannot sway the family to see that their loved one is in pain. They will not allow us to let them go, and they are incredibly angry at us for suggesting we will not attempt to force-feed them or bring them back to life when their heart stops.

We wonder, is it uneducated families? No, many of those demanding the most aggressive interventions are health care providers themselves. In the story that kept me awake, the daughter is a nurse. In the Rasouli case, where physicians sought to withdraw futile care, the wife of the patient was a family physician in Iran.

Are they expecting miracles?

Is it that they feel entitled to have whatever they want? Do people regard healthcare as a concierge-style service where they can pick and choose whatever options they like?

Ian says:

Thank goodness the passengers don't come into the flight deck and try to tell me how to do my job! If they told me I should land the airplane even though conditions were unsafe, I'd say 'no way!'

I guess it's not that simple in medicine, as health care is a right and a public service. We do have a duty to help people, but sometimes we disagree on what that looks like.

We encourage patients to have some skepticism, to ask questions, and to take part in their health. They put their trust in us to choose the right treatment, to recognize when we need to consult a specialist, and to guide them through the tough times. But when it comes to death and dying, people get squeamish. The trust vanishes.

 

Many families are quite reasonable. They might have a hard time letting go, but gradually, they start to see that mom is really unwell and does not seem comfortable, and they let us do our best to care for her. It's the egregious cases that stick in my mind, the ones where I feel like I've been asked to hurt someone despite my protestations.

I'm not advocating for a return to paternalism. Tell us your goals, your values: what is important to you? Just as you trust a pilot to adapt the flight plan to bring you safely to your destination, trust that your healthcare providers will do their best to shepherd you through your illness.

Discussions usually involved patients with advanced age, multiple co-morbidities, and poor quality of life. Many of these patients do not have Advance Directives, and even if they do, their families do not have to respect their wishes and neither does the law.

The patients are often too unwell to speak for themselves and so it is the family that requests things like resuscitation (as opposed to DNR), artificial feeding (feeding tubes), or what we call "active medical management" which means 'usual treatment' (as opposed to comfort-focused care) in the context of someone who is dying.

Instead of facing what is a natural part of life with grace and dignity, some patients are not allowed this opportunity. They are instead medicalized, which in some cases means brutalized.

A patient who hasn't eaten for weeks is malnourished, yes. That is the progression of her dementia. She has lost the ability to swallow. Her family wants her "helped" by putting a nasogastric (NG) tube into her stomach. She's dying, and this may delay it, but it might also hasten it. Regardless of how long she lives, her last days will be uncomfortable, plagued with complications.

In the face of death, food and hope are highly seductive. But . . . I was left wondering: Does our need to feed our dying loved ones blind us to what’s really best for them? – Dr. Jessica Nutik Zitter, Food and the Dying Patient

Doctors are reluctant to participate in things that seem like torture. We swore an oath that we would not. We try our best to keep the patient's best interests in mind, but after we've fought and fought, sometimes we give in, tired out and afraid of being sued.

Samuel Beckett puts it best:

And when they cannot swallow any more someone rams a tube down their gullet, or up their rectum, and fills them full of vitaminized pap, so as not to be accused of murder.” – Samuel Beckett in “Malone Dies”

 

Two days after the first article, Mr Blackwell looked at the issue from another angle:

Doctors more reluctant to clash with families over end-of-life decisions in wake of Supreme Court ruling (Read)


He's right. We are starting to become crippled by fear. Those of us who aren't yet burnt out try our very best to protect the ethical standards we were trained to uphold. But, we all reach a point where we are tired of being screamed at, tired of seeing nurses driven to tears, and most of all, terrified that we will lose the opportunity to continue in the profession that we value so greatly.

We do what is asked even though we know it is wrong – a disgusting thought. I am young and not yet burned out, but I'm heading there fast because I cannot reconcile the idea of going to work every day and being asked to harm people. This angst makes it so much harder to enjoy all the wonderful moments and to remain humbled by the privilege to care for others.

I see the awe that Ian still has for flying, working as part of a team, taking charge of a metal can full of people who are flying home or somewhere interesting, hurtling through the sky thanks to some combination of physics and magic. Medicine can be that awe-inspiring too.

I don't want to quit. This "job" is so much more than that to me, but slowly the 'job' of being a doctor is ruining my love for medicine.

Social Determinants of Health (#SDOH); the bigger solution

When thinking about the health of a population, it seems that many acknowledge the role of public health and preventative medicine. We talk often about the context of the patient, their "Social Determinants of Health."

On a 1:1 clinical encounter, I often feel like I'm hardly doing anything useful. I'm just treating some numbers, doing something to the patient, not really doing anything for the patient.

It Seems I'm  'spit-polishing' the giant dent in the car, when I help an obese, diabetic patient adjust their dose of insulin.

You  could  take it in for repairs... but maybe better to have prevented this? (Image from  Bob Ottenhoff )

You could take it in for repairs... but maybe better to have prevented this? (Image from Bob Ottenhoff)

It's not clear how much of a difference this test-ordering, medication optimizing, target-setting, or patient educating makes. It feels like we are "helping" but at the same time, it feels often that we are just occupying time and resources when we could be investing these in a more effective way.

Dr. Leana Wen, writing Help patients by addressing the health of the community for KevinMD, puts it well:

We need comprehensive strategies that promote health and target problems “upstream.” We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there — these are Band-Aids, not lasting solutions. Our communities need innovative approaches to pressing issues like homelessness, drug addiction, obesity, and lack of mental health services.

The Canadian Centre for Policy Alternatives "gets it." Their paper, Sustainable health care begins with the social determinants of health: It’s time to get it right concisely summarizes the data and emphasizes that solutions that decrease spending on the medical aspects of health (eg. private healthcare) will only worsen economic disparity, worsening health.

How do we convince governments, who must work within the bounds of election cycles, that a long-term plan that addresses patients bigger needs is the wisest choice?