My talks at #FMF2016: Goldilocks approach to DM2 in elders, and Less is More Med

I'm really excited to be at FMF 2016 in Vancouver this year! It was two years ago in Quebec City that I presented on Less is More Medicine for the first time, and it was an incredible experience. 

I got to see this message resonate, empower the audience of my peers to act and improve their every day practice, and learn from them about the challenges and successes along the way. I can't wait to do it again!

Slides and handouts (you asked!) will be posted after the talks in the media/talks section.

Choosing Wisely Canada Talks

Earlier this month, I participated in a Choosing Wisely Canada Talks webinar. Drs Kimberly Wintemute and Anthony Train shared insights around a clinician's professional obligations and led a discussion around practical tips for having conversations with patients in these scenarios. You can see their talk and others in the Choosing Wisely Canada Talks series online.

This primary care discussion was incredibly relevant, and we covered a few tough topics including:

  1. A healthy patient requesting non-indicated screening blood work
  2. A patient requesting unnecessary imaging eg. MRI for lower back pain
  3. When a naturopath has told patient to ask MD to order a series of blood work
  4. A patient with a viral infection insisting on antibiotics
  5. Chronic use of sedatives/hypnotics including benzodiazepines in an older patient

It was great to have a mixture of people, including a patient voice, in the webinar. Some of the themes that emerged were around building a trusting relationship, exploring the patient's fears or goals and addressing those, having a discussion about risks vs benefits, using analogies/humour to convey a message, and using physical exam and other techniques to reassure patients.


"Choosing Wisely Talks take place on the 1st Thursday of every month from 12pm-1pm ET. Each workshop is led by an inspiring guest speaker, usually someone who has made significant gains in implementing the Choosing Wisely recommendations. Through a webinar format, participants tune-in to a live presentation by the guest speaker, followed by an interactive Q&A discussion. Participants usually leave each workshop with:

  • A greater appreciation for the impact of overuse
  • Ideas and inspiration for their own Choosing Wisely implementation project
  • A better grasp on potential barriers and opportunities to successful implementation"

 

Go to the website and use the right-hand menu to add these valuable events to your calendar or sign up for the newsletter. The next session is November 3rd from 12-1PM Eastern Time.

Is it worth it? The role of Health Technology Assessment (HTA) and using evidence with patients

"These are my people," I thought to myself on the long plane ride West, destined for home to a verdant explosion of nature after three days in snowy Ottawa. Maybe it was the season, but I think it was more the people around me that reignited my enthusiasm for change in health care.

In April, I was invited to Ottawa to be a part of the Canadian Agency for Drugs and Technologies in Health (CADTH) symposium closing plenary on the subject of Health Technology Assessment (HTA), a term that I had (embarrassingly!) not really heard of until receiving that invitation.

Despite feeling woefully out of place as a mere clinician, surrounded by successful policy analysts, clever researchers, health economists, and seasoned advocates, I had an incredible time. As I milled about taking in various presentations and getting my feet wet as part of a panel on Disinvestment, I found myself suddenly realize: everyone around me "gets" it.

What a gift: when you are asked to share your passion, say whatever you want to say, and know that the people listening are listening and nodding "yes" to some of the things that fall out of your mouth?

As I think more and more about how I can have a positive impact on the health and well-being of people, I think about the role of HTA in policy change, and about how evidence belongs to everyone. Being a bit camera-phobic I was reluctant to highlight this 8 minute video, but it was an honour that I do not wish to squander and I hope that some of what I said resonates with you too.

The 2017 CADTH Symposium is Apr 23-25, with the theme "Measuring Value in Theory and the Real World." If you are a student or patient group representative, you may be eligible for a travel scholarship. Check it out!

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.

 

Making change: The Right Care Movement

If you are reading this, you already know there is an epidemic of overuse in health care. Yes, there is underuse too, and this has been the subject of many lobbying and quality improvement initiatives to date. The medical-industrial complex, particularly in the United States, has capitalized on the fears of individuals who worry they might be victims of underuse, to the tune of billions in unnecessary and harmful "just to be sure" testing, medications, and procedures.

Of course the health of individuals and populations is primary, but we cannot discuss this in isolation, without due attention to cost and sustainability. Given the finite resources we have in health care, we can't afford to throw away the precious time of patients and clinicians, or the money of patients and taxpayers. The best way to fix either problem is to see them – under- and over-use – as one. We need the right amount of care.

Who doesn't dream of a problem in which all you have to do is shuffle the deck to solve it!? This resonates strongly with my predisposition (and tiny amount of training) with Integrative Thinking.

The classic example of two sisters splitting an orange is a good illustration of the potential of integrative bargaining, as well as its elusiveness (Follett, 1940). Two sisters both want an orange, and they compromise by cutting the orange in half. What they would have discovered had they discussed it, however, is that one sister wanted the pulp for juice, and the other wanted the peel for a cake. Discovering that they each wanted different aspects of the orange would have helped the sisters to split the orange in a way that each gets the most individual utility out of the agreement
– Kirk D, Oettingen G. Gollwitzer, PM. (2011). Mental contrasting promotes integrative bargaining. International Journal of Conflict Management, 22(4), 324-341.

This is not a traditional way of thinking. The idea that "less" can lead to "more" is not intuitive. Some examples may help to illustrate the meaning of this when applied to health:

1.By ordering fewer unneeded tests and consultations for one patient (say, to review their cardiovascular profile), the clinician can instead emphasize and support the role of lifestyle changes and free up the patient's time and energy to exercise (which will improve their health far more than any cholesterol test or drug could).

2. If a patient can stop paying for a medication she doesn't need, she has a better chance of making rent payments that month, decreasing stress and the morbidity associated with homelessness as well as reducing the chance of an adverse event or side effect from medication.

3. If one patient's MRI for a sore knee is cancelled because it was planned to assess for a meniscus tear and is not needed as meniscus surgery is not shown to be effective, then timely access is now an option for another patient who needs that MRI (perhaps they've clinically had a stroke and the CT was normal, so the pattern of pathology on the brain MRI would change the treatment plan to prevent further strokes)

It goes on. However, because many people don't think about the big picture for themselves, their practice, or society as a whole, it can be hard to convince them to consider the 'Less is More' mentality. They may only hear "less" and run screaming.

This is why we need to create a huge swell of support, a cultural shift to make the discussion about overuse and underuse the norm. Jeanne Lenzer explains more about how the Lown Institute is attempting this with the Right Care Alliance in The Backstory—Is US healthcare a frontier for a new civil rights movement?

Source: http://blogs.bmj.com/bmj/2016/05/13/jeanne...

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...

Toolkits from Choosing Wisely Canada

At the Choosing Wisely national meeting March 30th, Choosing Wisely Canada (CWC) announced a new direction.

In lieu of the 10 million challenge, they are instead putting significant effort into empowering CWC enthusiasts by way of facilitating "DIY Toolkits."

These tool-kits are PDF documents, starting with a catchy title and cover art (provided by CWC), and filled with user-generated content, meant to enable you to apply some of the Choosing Wisely recommendations to your institution or practice. So far, the topics include reducing unnecessary indwelling (Foley) catheter use, proton-pump inhibitor prescriptions, 2nd units of red blood cell transfusions, pre-operative investigation, and sedative/hypnotic use in the elderly.

Click on the image below to check out the first 5 or go to the page to learn how to submit your own:

Source: http://www.choosingwiselycanada.org/in-act...

COVER FEATURE: Dr Otte/Less is More Medicine in Canadian Family Physican

It is a pleasure to announce that the March edition of the Canadian Family Physician (CFP) almost entirely consists of articles that pertain to the 'right amount' of medicine; among them is a cover story about me (Jessica Otte) and Less is More Medicine.

Check out the cover article for yourself!

The CFP has recently shifted their covers to feature physicians who are practicing social accountability in medicine. It was an honour to be featured and, in so doing, bring attention to the need for real patient-centred care and consideration of the harms of too much medicine.

This month's journal is a seminal edition for the fight to find patients the right health care, thanks to the other related articles showcased:

Use your B.R.A.I.N. A Decision Support Tool

The Centre for Collaboration, Motivation, and Innovation (CCMI) is a non-profit organization dedicated to building skills and confidence for better health and health care. Their vision is "to improve health outcomes through helping people take active roles in their health."

The BRAIN Informed Decision Making Aid

Achieving this vision entails the development of tools that can facilitate patient-provider conversations. To that end, they have adapted the BRAIN Informed Decision Making tool from the International Childbirth Association.

At the recent BC Patient Safety Quality Council's Quality Forum (#QF16), I was asked to give a talk on Choosing Wisely and was put into the "Patient Empowerment" breakout session. It was fortuitous that my talk preceded that of the CCMI team as I got to see their presentation on the tool and learn about its development (slides accessible here).

Helping a patient to explore the [B]enefits, [R]isks, [A]lternatives, their [I]ntuition, and [N]ext steps, the BRAIN tool can assist people navigating any significant health choice.

You can view and download the PDF on the CCMI's website. The simple format and generalizability means it could easily become a 'go to' tool for patients and clinicians who wish to engage in shared decision-making.

Please feel free to leave your feedback on this tool in the comments section below; the input can be forwarded to the CCMI team. Has it been a helpful tool for you as a patient or caregiver? Do your patients find the format straightforward?
 

More

Seeking more tools like this to facilitate patient-provider discussions around important health choices? Less is More includes a list of mainly Shared Decision Making Tools, in the hands-on resource section.

Source: http://www.centrecmi.ca/wp-content/uploads...