For Smart Medicine, Choose Wisely
A student says to the teacher, “Will I get in trouble for something I didn’t do?” The teacher says, “Of course not.” The student replies, “Great, I didn’t do my homework.”
Doctors do their homework. Ordering all sorts of tests, treatments and procedures can feel right and safe. Why do less?
However, all those interventions come with possible side effects, which are often underestimated.
“Being thorough, leaving no stone unturned – the downside is it doesn’t take into account the consequences of doing more,” says, Dr. Wendy Levinson, Chair of Choosing Wisely Canada (CWC). The organization is the national voice for reducing unnecessary tests and treatments in health care. CWC explains that such superfluous interventions:
- do not add value for patients;
- potentially expose patients to harm;
- lead to more testing to investigate false positives;
- contribute to unwarranted stress for patients and their families; and
- consume precious time and resources.
Will doctors get in trouble for something they don’t do? That’s a concern for some, acknowledges Dr. Levinson, a Professor of Medicine at the University of Toronto. She says doctors might wonder if their reluctance to order a particular test or procedure might result in a patient complaint to the CPSO.
Dr. Judith Plante, a Council member and member of the College’s Inquiries, Complaints and Reports Committee (ICRC), can offer some reassurance in that respect. “We fully endorse the mandate of Choosing Wisely and the ICRC supports the effort to reduce unnecessary testing,” she said.
Because each patient situation is unique, she urges physicians and patients to use CWC materials to determine an appropriate treatment plan together. “The CWC recommendations can spur important conversations. A physician who communicates with his or her patient, listens to their concerns and provides an explanation as to why a particular test or procedure is not in the patient’s best interest is not likely to be subject to a complaint,” she said.
If the patient does, in fact, proceed with a complaint, the physician should be able to present evidence that he or she documented the conversation, said Dr. Plante.
This April marks the fifth anniversary of CWC (choosingwiselycanada.org), run by a team from the University of Toronto, the Canadian Medical Association and St. Michael’s Hospital in Toronto. The broader Choosing Wisely movement has a presence in 20 countries.
CWC has partnered with professional societies representing the range of clinical specialties to create recommendations (reviewed yearly). These identify tests, treatments and procedures commonly used in each specialty that 1) aren’t supported by evidence, and 2) could expose patients to harm.
The CWC website includes the lists (broken down into 50 categories), along with how-to resources, implementation toolkits, and success stories from clinicians and hospitals.
If so many tests, treatments and procedures are unwarranted — and can in fact do more harm than good — what’s the rationale for continuing them?
There are several drivers, says CWC. Defensive medicine and a fear of trouble or malpractice lawsuits can lead to over-investigations. So can practice habits that are hard to break, evidence or not.
Some systems encourage (or reward) over-ordering. In other
cases, patients are seen to insist on a certain test, treatment or procedure (though Dr. Levinson says doctors overestimate how much patients really demand them).
The CWC recommendations aren’t meant to dictate all decisions or supplant medical judgment, but aim to trigger conversations with patients. CWC puts four questions front and centre:
- Is this test, treatment or procedure really needed?
- What are the downsides?
- Are there simpler, safer options?
- What happens if you do nothing?
“If you have these conversations, you’ll discover that patients want reassurance,” says Dr. Levinson, an expert in the field of physician-patient communication.
Such conversations can give patients context for decisions, draw out their concerns and involve them so they’re on board.
When patients and their families are not on board, that deserves a conversation too. Dr. Levinson gives the example of a child brought into emergency after hitting his head during a hockey game.
If everything seems okay, you could leave out a CT scan. What if the parents are extremely anxious? Ordering a CT might feel like the safest thing to do, and would give mom and dad peace of mind. No one would fault (or sue) the doctor for the order. The fact that the child gets excess radiation, or that a false positive leads to more invasive tests … well, would anyone blame the doctor?
Addressing the CWC’s four questions goes a long way to avoiding an easy but unneeded course of action. Maybe the parents in this case will agree with the doctor’s conclusion. Or maybe they share the story of a relative who died from a fall after an undiagnosed subdural hematoma. That’s an important element to consider in a conversation too.
At least such conversations help lead to the best possible decisions. Many tests, treatments and procedures may be unnecessary. Open dialogues with patients never are.