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?


VIDEO: Speed, Need, and Greed: Dr Iona Heath: Articulating why we need Less is More in Health Care

Dr Iona Heath is to me a sage leader in understanding and rejecting the existence of "too much medicine." She is not just a philosopher and crusader for the cause, but a (retired) GP who has practiced what she preaches. Her role as a physician engenders the trust of colleagues, but it is her compassion for the patient and advocacy for people (not doctors) that resonates with me.

Every time I violate my Less is More philosophy, I aspire to do better. There are many things - including speed, need, and greed - that motivate me and my colleagues to practice too much medicine, but every day I get a little better at overcoming these.

She gave a similar, inspiring talk in Vancouver which was when I first met her. I am honoured to see that she refers to me and this site at the beginning of her talk at the Londonwide LMCs' Building Resilience: Taking Control Conference 2015. View it below:

This video is about Dr Iona Heath's presentation at the Londonwide LMCs' conference Building Resilience - Taking Control


The Upshot reflects: Patients overestimate benefit and underestimate harm of tests & treatments

In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.

Their Conclusions and Relevance section explains the take-away it nicely:

The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.

This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.

For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer. 

94% of patients overestimated the benefits of bowel cancer screening.

Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:

Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.

 These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.


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)

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.

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


Plans for Less is More

After the Preventing Overdiagnosis Conference, I took almost a month off, which we spent tootling around Iceland in a LandRover and enjoying the food and culture of Brussels, Brugge, and Paris.

Back home now, I am also back into the swing of things. It is full speed ahead! In brief:

  • Today, Dr James McCormack (@medmyths) and I will be presenting to the UBC Medicine students in their Doctor, Patient, and Society (DPAS) 420 class on Less is More in Medicine
  • I'll be doing various talks on this subject for the Family Medicine Forum (Nov 15, Quebec), Vancouver General Hospital Family Practice Rounds (Dec 9, Vancouver), the UBC CPD Post Graduate Review in Family Medicine (Feb 25, Vancouver), and the Rural and Remote Medicine conference (Apr 10, Montreal)
  • To the website, I've added a Media section, which will list any news articles or talks related to the site, and a Declaration section, detailing no conflicts of interest. Many other updates are needed!
  • I have tones of notes from the Preventing Overdiagnosis Conference and will try to summarize some of the themes in a following blog post, and update portions of the website accordingly (like the People section - lots of great names to add)

There's so much being written on this subject right now, it is hard to keep up. As busy as it makes me, it is a good problem to have.


Choosing Wisely - a catchy music video by James McCormack

"It might seem crazy . . . Less is More can often be the Best Way."

Dr James McCormack, co-host of the Best Science (BS) Medicine Podcast at Therapeutics Education Collaboration, created this video. It's a parody of the Pharrell Williams song "Happy," adapted to promote the concepts of evidence-based medicine, shared decision making and common sense to healthcare providers and patients.

The catchy tune highlights some suggestions from the Choosing Wisely campaign (US) and the Choosing Wisely Canada recommendations as well as ideas for using your common sense to be healthy!

Check out the video, show it to your doctor or patients, and start a healthy Less IS More conversation.

James and I will be doing a talk to the UBC Medical students this fall; I only hope we can be half as engaging. Great work, James!

Tensions Creating Less is More; Quality and Quantity

Per my last post, I just spent a week getting fired up about Integrative Thinking, thanks to the CMA and the Rotman School of Management.

The "Right Care" or "Appropriateness in Medicine" or "Less is More Medicine" movement – whatever you want to call it – is a synthesis of the tensions in the healthcare system that exist between the system's needs and the patients' needs. There are common goals, and even tensions between those, eg. between high quality care and a minimally disruptive process, between an efficient system and comprehensive services, between sustainability and quality, and between patient empowerment and provider accountability.

It is possible to have the "best of both worlds," but it is going to take a lot of work to figure out how to get there. Less is More begins by challenging the assumption that "More is Better." By accepting that quality and quantity are not inextricably linked, we open up a world of possibilities for the future of healthcare in Canada. Unsurprisingly, quality and quantity are often at odds for patients who are in their final years, which means that the "less is more" approach often naturally arises in end-of-life care.

In math class as a a kid, I always liked to solve a problem and then do the problem in reverse, to make sure my answer was right. Thinking about "appropriateness in medicine" I realized that maybe we already do have the solution. If I work backwards, will it ensure it's the 'right answer'? Or at least, one possible solution? Can we integrate High Quantity Care with Low Quantity Care to create the Right CareCan quality and quantity be reconciled for something in between, like the "just right bowl" of porridge that Goldilocks found?

The current, unsustainable and ineffective state of healthcare is in part due to the pathological thinking that arises from funding quantity rather than quality of care. By incentivizing disease rather than health care, it's no wonder cost are soaring and health outcomes are slipping. However, it is exceedingly difficult to measure quality, as we've yet to agree on a definition. One idea are QALYs, Quality-Adjusted Life Years, but this measure is not without issue.

If we pick the wrong measure, "payment for performance" models could also lead us astray. This year, we've learned that high patient satisfaction is correlated with increased morbidity and mortality. So, even though institutions and careers were made with this measure, giving patients what they want is not actually in the interest of their health!

There are many options:

-  Performance Measures: find useful quality measures, and create methods for measuring physician/nurse/system/etc. performance; make it auditable, provide feedback, unlicense those whose practices deviate significantly. This is scary for doctors because it diminishes our autonomy, something we value greatly, but it could lead to better access, quality, and efficacy. It may be quite a challenge since patients are ultimately responsible for their health. No matter what a nurse or physician does, there is a lot of the patient's health that is beyond the healthcare provider's control. As well it should be, since we ought to be shifting away from paternalism to patient-centred care, where people take ownership for their health and partner with experts who can guide them along the way.

- Bundled payments: where providers get a lump sum for the handling of one process (eg. hip replacement: it would include pre-, intra- and post-operative recovery including management of complications). Given a lump sum, the team would be motivated to provide the best care, which likely entails shorter stay, fewer medications, better quality surgery, best outcomes, etc. If they manage to save a lot of money by making the care efficient and effective, they profit. If they do a bad job, it costs the providers - not the system. This model provides a disincentive for unnecessary care, but doesn't allow for a lot of self-direction. Special consideration would be needed to account for more challenging patient populations.

- One price per patient per year: no matter how well or sick the individual, the system would have a fixed amount to care for them. This encourages providers to emphasize and support preventative health measures, and to use tests/treatments judiciously. For example, a practice would probably elect to follow Evidence-Based practices that show high value and efficacy. For example, doing colon cancer screening (a small cost) will allow detection and treatment of colon cancer at a time where it would be cost-efficient as well as in the best interests of the patient to intervene; if you don't screen, you find the colon cancer later and it is harder and more expensive to treat. Difficulties? It would take a long time to bear out successes. Also, the sickest patients might never find physicians. Also, physicians may have a hard time combating the consumer culture of "more is better" and thus be unable to provide efficient care.

- ?? More

I have a lot more reading and thinking and integrating to do. The next steps for me involve seeking out more opposing points of view, and to find those, I just have to talk to more and more people about these ideas and hope that I find lots of conflict and disagreement.