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.


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.


    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.

    Quality Forum: Choosing Wisely by Jessica Otte on Prezi

    10 minutes: That's how much time I had to tell the audience at the BC Quality Forum about the Choosing Wisely Canada campaign.

    10 minutes may be the schedule duration of a routine patient visit with their GP. That's a short amount of time! In this short time it is hard to have a fulsome discussion with a patient about their condition, review their history, check in with their goals, and plan a strategy of treatment. It's even harder when the patient has 3 things they want to discuss!

    10 minutes is not enough time to change the world - unless you do it a little bit at a time! That's why the take-away from my talk was simple:

    If you feel you may need more, check out the slides on Prezi.

    If you want to see other talks or articles I've done, go to the Media/Talks section.


    A New Kind of Rounds: Type 2 Diabetes in the Elderly CME

    Thanks to my local Division of Family Practice and the Practice Support Program (PSP), we were able to put together "A New Kind of Rounds" event all about helping patients find the right amount of medicine. 

    Our first event, focussed on Type 2 Diabetes in the Elderly, and specifically the harms of treating this too aggressively. Inspired by the Lown Institute's RightCare Rounds and the DoNoHarm Project, we started with patient cases in which the patient's perspective highlighted the burden of treatment and the potential harms of too much medicine.

    After small-group case learning, I presented a didactic session reviewing the unique factors that change our approach to management in the elderly, the best available evidence on diagnosis and treatment targets, the current guidelines, and some resources that clinicians and patients can refer to in order to make shared decisions about the "right amount" of care.

    The event was well-attended and it was heartwarming to see the level of engagement on this topic from clinicians in our community; we are reviewing the evaluations to consider some changes to the format. Participants also generated an amazing of possible topics for future events, from hypertension to cancer-screening, and anti-psychotic use in the elderly to the annual physical. 

    The slides are available here.

    Your feedback is most welcome. You can comment below or e-mail. 

    My other lectures can be viewed here.


    The Most Important #ChoosingWisely List: Med Students & Trainees

    Please join me in enthusiastically applying the latest Choosing Wisely Canada recommendations, as developed by the Canadian Federation of Medical Students (CFMS) and the Fédération médicale étudiante du Québec (FMEQ).

    This amazing list of 6 items for Medical Students and Trainees to question is extremely important. It does a few things above and beyond what the other Choosing Wisely Canada lists could. Namely, the list:

    • Creates and promotes a culture of appropriateness in care early on in the careers of physicians, ensuring this way of thinking is embedded in their style of practice
    • Recognizes the professionalism, critical-thinking ability, and ethical intelligence of young clinicians
    • Engages medical educators and recognizes the mutual influence that learners and instructors can have on each other's practice
    • Is directed squarely at providers; while discussion between patient and provider may seem notably absent, each of the items is patient centred at a high-level; the list ensures that the goals of the patient – not the learner – are paramount, and that the learner will advocate in this regard

    Hopefully the Students and Trainees Advocating for Resource Stewardship (STARS), students selected to champion the Choosing Wisely campaign, will be able to integrate these Top 6 into their medical schools' curricula.

    Congratulations to the members of CFMS, FMEQ, and STARS on this fantastic work.

    Review the 'Six Things Medical Students and Trainees Should Question' list.


    Transfusion Medicine for Physicians

    Did you know that there is an online, CME-Accredited course regarding the use of blood products?

    In the area of transfusions, Less is often more!

    Emergency and Family physicians, hospitalists, internists, residents and surgeons could all benefit from learning the when, why, and hows of transfusion.


    See the PDF Flyer or go to the website to learn more and register!


    Overall Learning Objectives:
    After participation in this course, the learner will:

    1. Appropriately interpret clinical signs and symptoms of reduced oxygen carrying capacity and utilize hemoglobin concentration to determine need for RBC transfusion.
    2. Be confident their RBC transfusion ordering practice is up to date and reflects current literature.
    3. Apply the appropriate elements of informed consent for transfusion.
    4. Appreciate the indirect relationship of common coagulation tests to bleeding risk and the role of frozen plasma transfusion.
    5. Recognize and respond appropriately to adverse transfusion events or reactions.
    6. Know where to seek further advice on transfusion management.



    CMA General Council (#cmagc): A Success for Canadian Health Care

    Advocacy and policy making is just one of the levels I am working at in order to improve health care for Canadians. Sometimes there are direct links to a "Less is More" approach. The Canadian Medical Association (CMA) calls this kind of topic "appropriateness." Although the CMA's annual meeting (General Council) this year only had a few ties to this way of thinking, a few readers have asked me about the event as a whole and so I share my reflections here:

    It was an incredible General Council (GC) in Halifax, NS this August. I was able to participate as a Delegate for British Columbia and I cannot explain the feeling of immense purpose and privilege involved in voting on the policy and positions of the national organization of physicians; I was elated to be a part of the formation of some incredibly socially progressive resolutions that will have a real and positive impact on the health of Canadians. We resolved to divest our organization of investments in fossil fuels, to support the principal of a universal/national pharmacare program and a basic guaranteed minimum income, to encourage informed discussions around childhood vaccination in all school age children, and to endorse harm reduction strategies like a national guideline for naloxone availability (for opiate overdoses).

    There was some outcry, understandably, from those who live in areas of the country whose economies depend almost entirely on the fossil fuel industry. They were out-voted. We cheered when we made the symbolic gesture – it was not a lot of money for our organization to re-invest in other industries. It was just an incredible statement for our organization to show that the health of the planet affects the health of its people, and we are willing to take the longer view.

    The general assembly agreed to disagree on the exact details of how a patient would access physician-assisted death; council continued to extend the privilege of speaking to all attendees which allowed many conscientious objectors (observers, not official delegates) to express their concerns about participation in this, now legal, act. We all trusted in the process of consultation involving government, the public, the CMA (through various other channels besides GC), and other interested bodies (regulatory colleges, insurers, etc.) and will wait to see what this more broad process concludes as far as the exact process for physicians and patients.

    It was all quite cordial, actually. The conscientious objectors were respectful and registered their concerns clearly. The voice of youth was loud and clear, with many young physicians and medical students participating as non-voting ambassadors, and a few of us resident and early career physicians voting as delegates. Our push for change was LOUD! The momentum built in the room and many of us felt like serious headway was made for our patients.

    As ever, we heard: “you young people are what is ruining our society.” In person the meeting was quite pleasant but those physicians following online, especially on twitter, were outraged.

    Mainly, it was those who opposed universal healthcare who were ashamed of what the CMA General Council had done. Everyone voting must be “left wing radicals” and “communists.” All the young people “lack the context” to create and endorse the correct resolutions. 

    But, we were there, and we did it. Yes, many of the resolutions we made and voted in may never come to fruition this year. We don’t have unlimited time and finances as an organization and to be effective we must focus on a few narrow issues. However, it is still a big win for Canadians to be able to reference this groundbreaking policy. Setting precedent and having a public record of endorsement of an organization as respected as the CMA may be just enough to help grassroots initiatives get the edge they need to grow into persuasive bringers of change.

    Thinking specifically about the “less is more” approach to health care, we also passed many resolutions to help strengthen palliative care programs to make them accessible for more people, and called for regulations around genetic testing/precision medicine and telemedicine [I was a Mover]; we warned that Canada cannot blaze forward with these technologies without consideration of the considerable risks they may pose for patients.

    We also recommended that our National Senior’s Strategy and the policy paper "A Prescription for Optimal Prescribing" be updated to include a specific section addressing polypharmacy, which passed on the consent agenda [I was a seconder]. See the video of my colleague, Mover Ralph Jones, speaking briefly to this motion after we knew it had passed, with what I suspect is a nod to Johanna Trimble of IsYourMomOnDrugs? 

    The CMA's incoming president for 2016-17 (our choice from BC), Dr Granger Avery, and our colleagues Drs Horvat and Routledge spoke to a disallowed motion that called for efficiency in our health care system. See their video here. Perhaps next year we can refine and submit more motions on appropriateness and efficiency? I have a few drafted already!

    In a few narrow ways and in the broader sense, GC was a key step forward in advancing efforts for more appropriate health care. With a strong emphasis on addressing the real determinates of health, the solution of de-emphasizing tests and treatments that are harmful or not necessary also gains strength. Slowly, recognition for the importance of health in all policies is emerging. If a person cannot afford food, it doesn’t really matter if their dose of blood pressure medication is optimized. Right?

    It feels fantastic to be a vocal part of an organization of 80 000 Canadian physicians that “get it.”

    Transforming the Canadian Healthcare System with Integrative Thinking

    I had the incredible privilege of participating in the inaugural class of a partnership between the Canadian Medical Association (CMA), the Provincial and Territorial Medical Associations (PTMAs), and the Rotman School of Management (University of Toronto).

    Forty physician leaders from across the country are spending a week together, learning about Integrative Thinking and its application to Transforming the Canadian Health Care System.

    My experience:

    - 1 week in a room with 40 flabbergastingly amazing physician leaders from across the country
    - Values: we all want to achieve the same things for patients, have similar values, and all have different ways to do it; some have tried and failed, some have succeeded, others are not sure where to start
    - Focus: on how to radically transform health care in Canada using Integrative Thinking
    - Experts: Rotman School of Management geniuses, the earnest and persuasive Brian Golden & the engaging and hilarious Jennifer Riel, as well as conflict superstar Janice Stein (who I remember watching on TVO as a teenager). Also "Outside Voices" representing PTMA leadership/government, with a call to action from a peer leader.
    - Background: the history of the technique of Integrated Thinking is nebulous, but in interviews, Roger Martin identified it as the common strategy used by many successful leaders use to work through impossible or "wicked" problems. It may be rooted in elements of Hegelian dialectic and is highlighted in F. Scott Fitzgerald's writing:

    The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see things as hopeless and yet be determined to make them otherwise.
    — F. Scott Fitzgerald

    - Technique: cracking the unsolvable problem by changing the rules, addressing assumptions, and employing the tension between two opposing models to create a third, better answer. And there are many of these better answers, never just one.

    The Rotman School of Management defines integrative thinking as:

    "the ability to constructively face the tensions of opposing models, and instead of choosing one at the expense of the other, generating a creative resolution of the tension in the form of a new model that contains elements of the individual models, but is superior to each . . .

    Integrative thinkers build models rather than choose between them . . .  they creatively resolve tensions without making costly trade-offs, turning challenges into opportunities."

    - Variations:

    1. weaving best elements of conflicting solutions together to make a better hybrid (HIDDEN GEM)
    2.  stretching or bending one model in a way that it can produce the best aspects of the opposing model (DOUBLE DOWN)
    3. re-framing the problem, taking smaller elements of it or changing the underlying problem (DECOMPOSITION)

    - Examples: Double down integration

    Wal-Mart Stores Inc. is an example, when the company thought it had to choose between protecting the environment or protecting the bottom line. Under attack from sustainability critics, the retailer doubled down, using its strong influence on its supply chain to push suppliers into greater sustainability without raising its overall costs.

    Read more in this handy summary, "Melding two thoughts to find the best approach," in the Globe and Mail; the original article is "Integrative Thinking in Three Ways." I could not find a free version but if you have a subscription you can read it in the Harvard Business Review.


    - Our Example: Our group had to design an acute care system that could get the best of patient empowerment and physician accountability. We designed an emergency room flow that had various points at which self-directed patients could enter or exit the system, with an advocate or medical expert able to guide them at each step along the way.

    We could have easily suggested Shared Decision Making where providers and patients work together to make decisions at every step (Variation 1), a totally patient-responsible system that somehow managed to uphold and employ physician guidance & expertise (Variation 2), or suggested that patient-directed care would be in some settings and paternalistic (provider-dictated) care would apply in others (eg. in an emergency, where the patient cannot be consulted) (Variation 3, kind of).
    Frankly our rough solution seemed to involve elements of each approach. As a group member said, "we gave the patient a paddle instead of sending them down the creek (of acute care) without one."

    Other considerations in the process:
    - reconsider 'opponents' in negotiation as partners in creative problem solving; you probably share common goals (eg. both government and physicians want good quality healthcare for patients); working with those in mind will help create a win for everyone
    - slow down, take a step back, and think about the needs you are addressing and challenge all assumptions before jumping to a solution
    - know the people that you are representing and frequently share with them and seek their input
    - create an institutional culture where conflicting ideas are embraced and used to make the projects and product better; encourage this with techniques like a rotating Devil's Advocate, focusing on common goals and values, and not forgetting about the psychology of political intelligence (which we learned through watching 12 Angry Men)

    How does this relate to Less is More?

    I assure you, it relates entirely! Furthermore, learning about Integrative thinking has allowed me to take a step back and look at the underlying needs, tensions, and to work through to some solutions. Plus, I need to round up some opposing viewpoints, because people who challenge the idea are my new best friends (for creating change)!

    Stay tuned for the next post.

    Follow Up: The Name of Cancer: Even Aboriginal Languages are Changing

    In my last post, I shared an article that advocated for changing the name of "pre-cancers" and "early cancers" to reflect their benign, watchable, or treatable natures. The hope in doing so is to remove the stigma of "The Big C" for patients, allowing them to see a clear difference between aggressive cancers and their indolent cousins.

    Working in the NWT and Nunavut, I must say that it warms my heart to see that Canadian Aboriginals are taking a big part in changing the terminology. Some of the words and phrases are so remarkably apt, perhaps we'll be borrowing them into English.

    Language officials in Nunavut released their new word for cancer this week.

    The new term “kagguti” comes from the Inuktitut word kagguaq, which means “knocked down out of natural order."

    It replaces “annia aaqqijuajunnangituq” or “an incurable ailment," which officials felt was giving people the wrong impression of the disease.

    I love the translation of the word kagguti, it explains cancer at a cellular level and on a personal one too. The cells have lost the signals that keep them from over-replicating, and the cancer could prevent a person from living their life in the expected or natural way.

    Read more on CBC News.