“Choosing Wisely” – time to import an American initiative into Canadian health care?
Here’s a startling but true story.
What’s so startling about that? The people who used the strips were not receiving any medications to lower their blood sugar levels, which meant that they had little to no chance of benefiting from frequent testing.
Why were the tests prescribed? A relatively small number of patients probably aggressively demanded frequent testing because they were convinced that more testing had to be a good thing, and nothing their doctor could say would persuade them otherwise. In another small number, there was probably something about the patient that made their doctor think that it was really important to test frequently. However, in the vast majority of those 49,000 people, I suspect the doctors gave little or no consideration to the cost of testing, and prescribed the test strips because it seemed like a reasonable thing to do.
Part of the current battle between the Ontario government and the Ontario Medical Association is focused on how to deal with the apparent wasteful use of tests. I suspect that a number of task forces will soon be established in the hope of changing how doctors order tests.
However, given the magnitude, complexity and rate of change of our health care system, establishing numerous task forces focused on individual technologies just doesn’t seem like a sustainable way of achieving change.
More importantly, I think we need a large cultural shift in how both doctors and patients think about testing in medicine. This won’t happen overnight, and will require lots of work. Physicians need to accept that although their primary responsibility is to their patients, it is also part of their job to think about the financial sustainability of the health care system. Patients need to recognize that tests are not “free” and that sometimes not having a test is just as good or better as having one.
Earlier this year, the American Board of Internal Medicine Foundation and nine major American physician organizations (including the American College of Physicians, the American College of Cardiology, and the American College of Radiology) launched an initiative called “Choosing Wisely”, focused on “….encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.” Interestingly, this is a joint initiative with Consumer Reports, which now features guidance about avoiding “unnecessary tests and treatments” on its web site.
It is early days, and we don’t know if Choosing Wisely will have any impact. Their task is particularly difficult because virtually all tests are useful – the challenge is to use the tests only in people who are likely to benefit from the results, and not use them in people who are unlikely to benefit or in whom they may do harm. That’s easier said than done.
However, at least these organizations are trying, and they have engaged the public in their efforts, through Consumer Reports. I think it is also commendable that they are doing this without government or insurance company involvement.
I sure would love to see Canada’s physician organizations do something similar.