To healthcare providers, Evidence-Based Medicine (EBM) and patient-centred care or shared decision making (SDM) are not new concepts.

We learn these in school and the theories and applications are constantly updated and disseminated via continued medical education. Medical learners provide new insights to their preceptors. Likewise, students absorb the practices being modeled around them. Seeing that your colleague does something a better way is a much more powerful force for change, than is reading an article online.

How can you share this or further improve on what you are already doing?

• Discover some of the hands on resources that can aid in discussions with your patients and their families
   
• Remember the context of the patient; use this to help begin a discussion about decisions. If you need help starting out with patient-centred care, try the FIFE Model.
  • In addition to our histories and physicals, we should asses the context of the person; it will be awkward at first, but gradually it becomes natural to ask (in your own way) about the following:

What are your Feelings about your health or the illness that brought you in?

Do you have Ideas of what it could be or why it happened?

How does it affect your daily Function, eg. does it affect your job or ability to look after your family?

What Expectations do you have, specifically, what are they hoping to get out of this visit? What are you hoping to hear? Is there a test, or treatment you think we should discuss?

• Take the Confronting Unnecessary Care online CME; review the issue of unnecessary care in Canada, become familiar with the resources of Choosing Wisely Canada – a physician-initiated campaign that encourages physicians and patients to have evidence-informed conversations about the necessity of medical tests and treatments so as to eliminate unnecessary care.

• Watch a video on good stewardship with clinical encounters from the National Physician Alliance (NPA); they suggest a a simple, 5-step plan to enable health care providers to discuss unnecessary tests and treatments with patients:
  • 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

• Try the Choosing Wisely Action Manual (developed by Washington State medical association) to learn how to implement Choosing Wisely recommendations in your practice (see Choosing Wisely Canada campaign)
  
   
• Be aware of or participate in creating your national medical association's policies regarding appropriateness, quality, efficiency, accountability, patient-centeredness, and cost of care
  • eg. Canadian Medical Association resolutions on appropriateness
    • (if you are a CMA member, watch the General Council 2013 Strategic Session #3- Clinical Decision-Making: Appropriateness and Accountability)
  • eg. American Medical Association Getting the most for our health care dollars
     
• Consider yourself a steward of the healthcare system; physicians, nurses, nurse-practioners, and allied health professionals together hold the key to maintaining the standard of care and transforming our system into one that delivers the best possible healthcare.
  • Sign a declaration to deliver The Right Care
  • Attend a conference to meet others who share these views
• Learn about screening tests, what makes a good one, and how to discuss risks and benefits with patients
  • Use the Making Sense of Screening guide (Making Sense of Science)
• Get comfortable De-prescribing
  • learn about polypharmacy and how to tackle it with help from deprescribing.org
     
• Review the evidence critically
  • Not sure how to find, read, critically appraise?
    • Easy to learn: The five stages of Evidence-Based Medicine (Oxford Centre for Evidence-Based Medicine)
  • Get the big picture from the summaries of meta-analyses done by the Cochrane Review
     
• Model it in your own practice 
  • Talk to your patients (and learners or preceptors) about this approach to medicine
    • consider sharing it at Rounds or incorporating examples of shared decision making/patient centred care and "right amount of care" in case examples
  • Educate patients about potential risks and harms of tests and treatments, and direct them to more resources on the subject
  • Know the guidelines for your health authority, region, society, or professional association. Know them so that you can discuss them and document when you purposely stray for them (out of date, not appropriate for the patient, etc) eg:
    • Canadian Task for On Preventative Health Care - guidelines: mainly screening, periodic health exams, and select specific topics
    • Alberta Health - Manuals and Guidelines: includes Towards Optimized Practice (TOPs) documents
    • Clinical Practice Guidelines and Protocols for British Columbia: a focus on chronic disease management
  • Find out the costs of tests or the number needed to treat (NNT) for an intervention
    • It shouldn't change your management if you are already delivering the right care, but knowing the cost of a test (eg. the numbers in this paper showing in 2000 that Canadian ER doctors had a limited awareness of costs) or how efficacious something is (eg the NNT) can help us to think twice to make sure we are doing the right thing

What do you think healthcare providers can do differently? E-mail your thoughts or tweet them to @LessIsMoreMed