As summer students working with Choosing Wisely Canada, we were part of a national, physician-led campaign to reduce unnecessary tests, treatments and procedures. The campaign has developed recommendations regarding commonly used tests, treatments or procedures that are not supported by evidence, and/or could expose patients to unnecessary harm. We feel strongly about the importance of physicians making thoughtful decisions about when care is needed, and when it is not, both to protect patients from physical and psychological risks of unnecessary treatment and to ensure appropriate use of our healthcare system’s resources.

While practising physicians from across Canada have been involved in developing specialty-specific lists, and promoting these within their specialty, the Choosing Wisely movement has not yet reached most medical students in Canada. We, along with the leadership at Choosing Wisely Canada, felt that the campaign should initiate a conversation in medical education about the need for more explicit resource stewardship training.

This is why we are so proud to have worked on creating the Choosing Wisely Canada recommendations for medical education. Like all Choosing Wisely lists, it includes recommendations for medical students on ensuring the best use of our health care resources. This list is endorsed by the Canadian Federation of Medical Students (CFMS) and the Fédération médicale étudiante du Québec (FMEQ).

Medical students feel discouraged from challenging overuse in the health care system

We sent out a survey to all medical students in the country to get their feedback on a draft list of potential recommendations. Nearly 2000 from across the country responded. We also asked medical students for additional comments and suggestions. Many of them emphasized why a simple thing like asking questions about appropriateness can seem so hard. “Because of the supervisor-student relationship, it is sometimes very awkward as a student to start a conversation about the appropriateness of ordering a particular test,” said one respondent. “Ultimately medical student behaviour is determined by supervisor behaviour. While encouraging students to question unnecessary tests is good, many students will be afraid anyways to risk being perceived as challenging their supervisor,” said another.

Medical education is a hierarchical environment and this environment can sometimes discourage students from asking questions, concerned that they may be perceived as challenging the authority of those more senior to them. “[Some of Choosing Wisely’s recommendations] may be difficult to implement in practice given the hierarchical nature of medicine (med students being lowest on the totem poll), and the culture/environment of work will play a big role in whether or not these are effective,” explained one student.

Since starting our clinical rotations, we’ve been confronted with similar barriers to providing high-value care to patients. We lack experience, and need guidance from our supervisors about many things, including when it is appropriate to order tests and medications, and when it is not. Medical students generally learn in environments that can promote overuse – such as academic hospitals where advanced health care technologies and access to an array of specialists is the norm. Evidence demonstrates that habits learned in training have a formative, long-lasting effect on appropriate use of tests and treatments by individual physicians.

When we receive praise from our supervisors for thinking through all of the possibilities and ruling them out, we sometimes misinterpret this as a message that doing more tests is always better. And that is because sometimes the praise for recognizing the rare diagnosis is not always balanced with praise for recognizing the need to demonstrate restraint when tests aren’t necessary. While we learned what tests to order in the classroom, we didn’t feel like we always learned when the tests are warranted and when they’re not. Like many of our fellow medical students in Canada, we feel that we are unable to initiate that conversation to ask about unnecessary care.

Six rules for medical students and trainees in health resource stewardship

Our hope is that this list – which was released this week – provides a framework for students, and their clinical supervisors, to have conversations about resource stewardship. Here are six ways medical students and trainees can avoid unnecessary or inappropriate tests, treatments and procedures in our health care system:

1. Do not suggest ordering the most invasive test before considering other less invasive options.
2. Do not suggest a test, treatment, or procedure that will not change the patient’s clinical course.
3. Do not hesitate to ask for clarification on tests, treatments, or procedures that you believe may be ordered inappropriately.
4. Do not miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary.
5. Do not suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.
6. Do not suggest ordering tests or treatments preemptively for the sole purpose of anticipating what your supervisor would want.

Practicing physicians through their medical societies have already taken up the call to combat unnecessary care. It is now our turn as medical students to add our voices to this movement and urge our training programs to help us to learn how to choose wisely.

The authors would like to acknowledge the contributions of Brian Wong and Karen Born in editing this blog.