Are you familiar with these phrases? These are part of an international movement that I believe has the greatest potential to make our health system sustainable.
All clinicians are aware of the waste in our system and examples are plentiful. Consider the back x-ray done for acute back pain after a weekend of yard work.
Evidence abounds that without any red flags in the clinical presentation, this x-ray is simply waste. Often, the busy doctor knows it is waste, but does not have the time, evidence, and alternate resources for the patient, or possibly the negotiating skills to explain why the test is unnecessary.
But waste it is!
We can all find many more examples. Why is there remarkable variation in the rates for some major surgical procedures between Regina and Saskatoon? Why is there duplication of tests by FD’s and consultants? Why are high-cost statins prescribed? How do people get antibiotics for a two-day illness consisting of a sore throat accompanied by a runny nose? Lots of evidence suggests 20% of what we do brings no benefit to our patients.
Now I know there always exceptions to these examples, but that’s why we call it clinical judgment. While making our system more efficient is essential, continuing to do wrong or unnecessary interventions more efficiently will still be waste.
The greatest potential for improving our system is changing clinical practice and models of care. And physicians worldwide are leading this initiative.
The American Board of Internal Medicine (ABIM) launched Choosing Wisely in 2012 in the US. This led eventually to the ABIM calling on all specialty organizations to list their top 5 “Things Providers and Patients Should Question”. http://www.choosingwisely.org/doctor-patient-lists/
So for the American Academy of Family Physicians, the back pain above is the first example. In fact, ABIM goes a step further. In their charter, Medical professionalism in the new millennium: a Physician Charter, they state physicians have a responsibility to promote health equity when resources are scarce. When Dr. Chris Simpson, President of CMA, spoke earlier in November about the “civic professionalism” of our students, this is part of what he was talking about.
“Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.” http://www.choosingwiselycanada.org
It is led by Dr. Wendy Levinson, an internist at U of T, for the CMA and supported by the SMA. “As physicians we are stewards of our patients’ health and it is our responsibility to partner with them in making appropriate choices for their care,” says Dr. Slavik, SMA President, “Doing so will not only ensure that our patients receive optimal care, but will also ensure that we have a sustainable healthcare system.”
Earlier this month, the Academy of Medical Royal Colleges in the UK released a report: “Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care”. One of the intriguing aspects of this report is how the potential savings of various interventions are listed in terms of both financial cost and carbon cost. It is quite sobering to see what we could do for our planet by choosing wisely! They also state “that doctors have an ethical duty not to waste.”
Appropriateness is another common term used for the same philosophy. Recently the province issued a call for a Physician Co-Lead, Clinical Appropriateness of Care Program. This will be a major initiative by the Ministry of Health.
And this is a major opportunity for the College of Medicine. What can be our role?
I see three: teaching these skills to the next generation; CME for current practitioners; and doing the research on clinical practice in our province that leads to everyone “choosing wisely”.
I had the opportunity 18 months ago to participate in a conference at Harvard on how we teach the knowledge and skills to support wise stewardship of health care resources. While we have been great at teaching patient-centered communication in the last 20 years, we do not teach the negotiating skills that allow practitioners and patients to easily deal with these issues. We must provide this content to our learners and model the corresponding care. Through CME, we must do the same for our practitioners.
The Canadian Institute for Health Research has a funding stream called the Strategy for Patient Oriented Research (SPOR) to support real-time research on clinical practice here in Saskatchewan. It is imperative our College of Medicine takes a leadership role in this important initiative and do the research on our practice here in Saskatchewan that will lead to better care and ideally to zero waste.
Please take the time to visit these websites, learn more about Choosing Wisely Canada, discuss with colleagues and friends, and tell me how we should lead at the College of Medicine.