Resource Stewardship Focus of Student-run Campaign

Test tubes

Choosing Wisely movement making its way into medical school

For years, the prevailing culture in medical education celebrated thoroughness — leaving no stone unturned in pursuit of a diagnosis. But a grassroots, student-led campaign is spreading the word that more is not necessarily better.

Since STARS’ (Students and Trainees Advocating for Resource Stewardship) 2015 launch, the Canadian-made effort is active in all 17 of the nation’s medical schools. It has also made its way across the globe, catalyzing medical students in Brazil, Italy, Japan, Norway and the United States to act as agents of change in the crisis of overuse.

“It’s more than what I could have ever imagined,” says Dr. William Silverstein, who was involved in Choosing Wisely Canada’s (CWC) development of the initiative as a University of Toronto medical student and now leads the STARS campaign.

Dr. William Silverstein
Dr. William Silverstein now leads the STARS campaign. (Photo Credit: Claudia Hung)

As a summer student at CWC, Dr. Silverstein became familiar with the concept of resource stewardship. When CWC released a report that found as much as 30 percent of the tests, treatments and procedures ordered were done so inappropriately, he took notice. But that message of overuse was not making its way into the medical school curriculum. Indeed, the culture in which he was taught still emphasized thoroughness with little focus on stewardship, he remembers.

“If someone came into the ER with chest pain, we would want to order a million-and-one tests just to impress our supervisors with our knowledge and commitment. Medical training rewarded that kind of initiative — it was perceived that the more tests you ordered, the more knowledge you had,” says Dr. Silverstein, now a general internal medicine fellow at the University of Toronto.

But as CWC and the broader resource stewardship movement has made clear — ordering unnecessary tests, treatments and procedures can lead to more harm than not. Indeed, Dr. Silverstein has, more than once, seen the downstream effects of unnecessary treatment. He remembers one older woman who came into his ER with delirium. Her son could not explain her behaviour — it was so unlike her, he told the medical staff. After some investigation, it was discovered she was prescribed benzodiazepines inappropriately, leading to her presentation.

Given that physician ordering behaviours originate in medical education, Dr. Silverstein says it was critical to bring medical students on board.

“If someone came into the ER with chest pain, we would want to order a million-and-one tests just to impress our supervisors”

“There is growing evidence that the habits established in medical training carry over to practice,” says Dr. Silverstein. “So the feeling was that if we could get in there early, while trainees were pre-clerks and medical students, we could empower them to start feeling comfortable enough to not overtreat or investigate, and to have those conversations with their preceptors and with each other about the risks and benefits of a particular test in a particular context.”

Dr. Matthew Hacker Teper says those conversations were invaluable in his medical education at the University of Toronto. He was a STARS participant in the 2020-2021 academic year and remembers sitting with fellow students and residents to talk through examples of overutilization. “We would work through a case of low back pain, bronchiolitis or some other commonly over-investigated presentation and, over pizza, we would just chat for an hour-and-a-half about the reasons to order and the reasons not to order various tests.”

Dr. Matthew Hacker Teper
Dr. Matthew Hacker Teper, a STARS participant in the 2020-2021 academic year.

Now, as an emergency medicine resident, Dr. Hacker Teper says those conversations gave him confidence to more easily engage his patients in discussions about overuse and potential harm. “You are taught early on in medical school not to delve into all the evidence with patients because it can sometimes be overwhelming. It’s a good lesson. But I think what STARS also taught me is that it’s okay to talk to patients about the reasons for not pursing a particular test and to explain how something could cause more harm than good. And when you demonstrate to patients your line of thinking, well, they are very reasonable about it,” he says. It is critical, he added, to ensure the patient knows what red flags they should be on the lookout for when they leave the hospital. And that, should one appear, it is important they return for further care and investigation.

Targets Behaviours

When STARS was being developed, the Canadian Federation of Medical Students (CFMS) and the Fédération médicale étudiante du Québec (FMEQ), in partnership with CWC, developed a list of “Six Things That Medical Students and Trainees Should Question”. The list steers clear of CWC’s usual disease-specific recommendations and instead targets student behaviours with respect to resource stewardship practices.

Recognizing that it could be intimidating for even the most confident medical trainee to question a preceptor’s decision to order a particular test, STARS helps lend legitimacy to the student voice, says Dr. Silverstein.

Given that physician ordering behaviours originate in medical education, Dr. Silverstein said it was critical to bring medical students on board.

“If the question [about a particular test] that the student asks leads the preceptor to reconsider the value of ordering it, that’s a good thing. And if there is a strong case for ordering the test, then the preceptor’s explanation could help the student understand the more complex diagnostic thinking of something they hadn’t considered before. And that is also a good thing,” says Dr. Silverstein.

In fact, he says he is heartened when he is supervising medical students that question the usefulness of a particular test, because it demonstrates critical thinking and a commitment to a patient’s well-being.

And teachers, in general, appear to be responding to such questions in that very spirit, said Dr. Hacker Teper. He notes lecturers have even taken to adding a slide or two about Choosing Wisely’s recommendations to their presentations.

“I think the tide is definitely turning within the faculty and there is a real appetite for resource stewardship within the profession,” says Dr. Hacker Teper.

Six Things

According to the list drawn up by CWC and Canadian medical residents, students and trainees should not:

  1. Order the most invasive test or treatment before considering less invasive options;
  2. Suggest a test, treatment or procedure that will not change a patient’s clinical course;
  3. Miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary;
  4. Hesitate to ask for clarification on tests, treatments or procedures they believe are unnecessary;
  5. Suggest ordering tests or performing procedures for the sole purpose of gaining clinical experience; or
  6. Order tests or treatments pre-emptively for the sole purpose of anticipating what your supervisor might want.