The entire medical community is talking about an issue causing risk and harm to patients across the country, but few patients are aware of this conversation.
My bet is that patients want to know, however, so here’s the difficult truth: almost one third of medical care in Canada is unnecessary and over testing and treatment is on the rise. Patients need to be empowered to ask about the risks caused by some tests and treatments, and whether they are really necessary. Remember when patients used to get their tonsils out when they had recurring sore throats? That doesn’t happen anymore because we realized it was overkill.
The conversation that is sweeping the medical community, both here and abroad, is called Choosing Wisely. Choosing Wisely began in the United States in 2012 and we started it in Canada in 2014 — just two short years ago. Part of our goal is to empower patients with information that enables them to speak to their doctor about what’s right for them and what’s not the best choice. Many within the medical community believe we are facing an epidemic of over-diagnosis and overtreatment.
Our campaign, Choosing Wisely Canada, is about improving care and doing tests and treatments that help, not harm, patients. It is not about containing cost. While cost of care is important for our overall health system, as doctors, our first and foremost concern is the health of our patients, and we realize that things must change in order to ensure that the treatments we prescribe are truly having the positive impact on patient health that they are intended to have.
Here’s why both patients and doctors need to change.
Patients sometimes ask for tests and treatments that are not necessarily in their best interest. And doctors often prescribe tests and procedures as a way of covering all possible bases.
Here’s an example. The overuse of powerful radiation scans such as CT and X-ray exposes patients to unnecessary radiation and increases cancer risk. People would be surprised to know how many patients ask their doctor for a CT or MRI scan because they have a headache or low back pain, despite that the tests aren’t recommended for these symptoms alone. And doctors often feel pressured to order the tests their patients request.
Another example: Some patients are being overprescribed antibiotics. The overuse and/or misuse of antibiotics in Canada needs to be talked about because it has real and potentially serious consequences. This includes more instances of antibiotic resistant superbugs like C.difficile being seen in hospitals across Canada.
We need to align doctors with best practice by getting them to stop using various interventions that are not supported by evidence. And we need patients to consider that tests and treatments may sometimes not be necessary and may have potential risks and side effects.
Part of this discussion has to include setting everyone’s expectations of doctor-patient interactions. Too often, both sides feel that a prescription or an ordered test should be the end result. But many times, less is more, and no treatment is the best treatment. Our campaign encourages working together to combat a culture of “more is better,” where the onus is on doctors to “do something” at each consultation, which has bred unbalanced decision-making.
This opinion piece is an updated version of an article that first appeared on the Evidence Network. It has been reprinted with their kind permission.
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Wise words and a good foundation to base your decisions on – having used the advertisements in our clinic -I find the response interesting – many patients don’t ‘get’ them -eg the weight lifting guy often leads to a conversation about how ‘ I must get back to the gym !’ Despite this they encourage conversation . I feel the important piece is to come together with your patients to understand why testing more or prescribing more is not always appropriate -but offering different care -be it education, team based solutions to manage eg pain or counselling support that allows the patient to leave the clinic with a positive plan for their presented issue -not just a negative ‘no we don’t do that ‘-to their requests for investigation . Many patients and physicians perceive there to be an underlying cost related goal to the campaign -which misses the point -but we have to acknowledge the far from infinite resources we have as well in order to be believable . It’s all in the delivery and coming together with patients in conversation – this often takes longer but we need to try to set expectations with our patients and involve them positively in decision making so that if we disagree with a request they trust in our reasoning behind that .
With planned cuts to our time modifiers here in Alberta -I wonder how difficult it will become to deliver the message within the constraints we will find ourselves working in. As the campaign goes forward , could there be a more positive angle on eg choosing wisely -but working together- this may set the scene for more positive dialogue with patients and help those of us in primary care deliver the message in a timely way.
I don’t know if the practice of administering Oxytocin/Pitocin is still prevailing, but unfortunately it was given to our daughter in the presence of CPD and with markedly delayed c/s. What does she know and how could she refuse recommendation of a “trusted” obstetrician? The birth trauma to the child with lifetime consequences occurred. At the teaching hospital in Vancouver area. Unreal mismanagement and a cover up.
I have read several papers I consider reliable that indicate that the post antibiotic era where any cut, including perhaps the needle jab of an injection, might result in an infection that cannot be treated – this might nearly shut down most sections in hospitals and yet we have known and used (for almost 100 years) at least one technology that can be used to treat superbug infections – namely phage therapy. It is my opinion that pharmaceutical companies and the healthcare systems need to offer and supply phage therapy free for patients when antibiotics fail or the patient is allergic to antibiotics. I believe that it ought to be a requirement for healthcare institutions to provide information on phage therapy when patients suffer from healthcare caused infections and when antibiotics fail – let the patient decide whether s/he might try the option of phage therapy. What are the ethical and moral implications of not informing patients about phage therapy? I believe it is cruel and unusual punishment and if any member of the medical team knows of phage therapy they become a bystander…., While writing this I have the 2013 report of Canada’s Chief Public Health Officer which states: “More than 200,000 patients get infections every year while receiving healthcare in Canada: more than 8,000 of these die as a result” – perhaps another reason to slow down and reduce the interventions and push for the establishment of ‘The Superbug Victim Felix d’Herelle Memorial Center for Compassionate and Experimental Phage Therapy’ to provide phage therapy to patients when antibiotics fail or when patients are allergic to antibiotics.
Docs are pressed for time. Patients want more of that time. We pts need Docs to explained why a test or antibiotic isn’t required. We’re adults and understand reason, we don’t want to cause ourselves harm. Regarding ” not supported by evidence”. I suspect that some evidence around PSA testing for men can and does cause long term harm. The same might be said for women asking for mamo coupled with ultrasound. Many docs are on the fence on having both…..rads mostly suggest both. For me the bottom line is advocate for your own health and piece of mind.
Docs might want to rethink prescribing opioids and getting people hooked then abandoning them because they’re hooked. It happens far too often & docs know it. We had a grandson die after 5 years because of Doctor bowing to govt pressure to cut c-sections at all costs. Govt then opened pocket book allowing sections which would have saved this child and parents years of emotional and physical pain. Us patients expect docs to advocate for us because our Ontario govt has ignored and sacrificed patients.
Thanks for reading
These articles are nice. However they are almost always written by those still working at a teaching hospital.
Never someone that is working full time outside of academia. I tried this when I first started but gave up after two years. I see the same thing at our clinic, where the new grads try their best to educate patients on the appropriateness of certain test. They will be in the room for 30 minutes and then spen another 10 minutes finishing up their note and another 10 minutes recovering from the ordeal.
After doing this repeatedly, they get worn down and eventually realize the path of least resistance also helps them with their sanity.
So I disagree with the Doc. If you want people to have a voice they need to pay some sort of fee. Then they will realize that healthcare is not “free”
I totally agree with Jim to charge a little for seeing doctor or having test done. People abuse the system in general when it is free.
I am one of those doc that spends the time to explain to patients abx are not needed and I work well outside of academia is a rural setting. I am remarkably surprised that most people listen a are quite reasonable when you explain why it is not needed. I book 10 min appts and it may take an extra couple of min but it is well worth it. I would disagree with your claim you need to spend 30 min to explain to patients in these cases. Most people are now realizing overuse of abx and opoids etc is a big deal and are willing to listen. There are of course patients you will never change and it usually becomes quickly evident who those are. In these cases, I tend to not argue and try delayed abx approach or ‘self strep treatment’ where pts wait to get the swab result before treating.
Where I disagree with Wendy is how to go about getting doctors to use less abx/testing. I hate to say this but getting doctors to change how they practice is like herding cats. We are self-governed and there is absolutely no oversight of physicians and in how they practice. One person can practice a completely different way than another. One doc could be prescribing double the abx to the same population of patients. We need our college to have more teeth and actually have mandatory teaching/learning for physicians that are far outside the curve of what is done. To do this, we need to track physicians. It is a shame we don’t track abx prescriptions of testing and how we compare.
Wendy:
This is a great article that patients really need to hear!! I am going to see if we can send this to all of our 42 Primary Care Networks in Alberta via our monthly e-newletter. I also would like to put this in some type of brochure for patients. they need to read this !! Thanks so much for writing it.