February 23, 2016
Reflections: As health-care providers the time has come to choose more wisely!
Dr. Jeremy Friedman is Associate Paediatrician-in-Chief at SickKids and Professor of Paediatrics at the University of Toronto.
In paediatric health care we are very focused on helping our patients and families as best we can, by promptly diagnosing their complaints, and treating them in the safest, most comfortable, least invasive manner possible. In some ways this was likely more straightforward, albeit less effective, in previous generations when there were fewer options in terms of diagnostic tests and available therapies. With each passing year novel and more sophisticated tests and medications become available and open the door to new information and possibilities.
It is widely reported that in North America approximately 30 per cent of all tests and therapies we order for our patients do not really help them, and in some cases may actually harm them. The unnecessary testing is sometimes further compounded by the reality that some will yield false positive results or find harmless ‘incidentalomas’ which may result in even more testing and unnecessary treatments and surgeries. How have we arrived at this point? Why would we order more tests than are absolutely required? Why would we take more blood samples, or use more ionizing radiation than needed? Why would we use a medication unless we are one hundred percent certain our patients will benefit from it? I’m certain it’s not because we don’t care enough about our patients. I’m also quite confident that it is not due to lack of IQ or inadequate training. So what is it then?
It is probably due to a combination of many different factors. We are all really afraid of ‘missing’ something that may harm the patient, and this is a big source of stress for many physicians. In addition there is also the potential for appearing negligent, and the risk of litigation. Sometimes we assume the patients and their families will expect us to do some testing or prescribe some treatment, and may be dissatisfied if we prefer to ‘watch and wait’. Sometimes in this era of increasingly ‘personalized’ medicine we are ironically guilty of doing everything to everyone without considering the child’s individual context; getting lost in the minutiae and losing sight of the big picture. Sometimes we are just conditioned to always ordering certain tests or treatments, or see our colleagues or supervisors order them and assume them to be the smartest approach. Sometimes we are impressed by the promise of newly touted tests and therapies, and may even be influenced by the passion or marketing of these products. Sometimes we just subconsciously mistake over-investigation or over-treatment for thoroughness or being really ‘caring’, or mistakenly assume that doing something must always be better than doing nothing.
So how do we reverse this trend? An interesting first step is the Choosing Wisely campaign. This is a movement that began in the US in April 2012 and has spread to Canada and at least 15 other countries over the last few years. The goal is to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures and help them make smart and effective choices to ensure the highest quality care. This clinician-led initiative has engaged physicians across all specialties, with over 50 national societies participating, creating their own ‘top 5’ list of recommendations of ‘what not to do’. Engagement amongst clinicians has been high, with enthusiastic endorsement from medical students (who created their own excellent list) as well as many hospitals and healthcare providers. One local Toronto hospital emergency department was able to show a 40 per cent decrease in overall testing after implementing some of the Choosing Wisely recommendations in their ED.
As most of the Choosing Wisely recommendations are aimed at adults, we at Sickkids decided to create our own ‘top 5’ list tailored specifically for the children we see at the hospital. We started by asking our colleagues in the lab, diagnostic imaging and pharmacy areas for suggestions of tests and therapies that they thought were being inappropriately ordered. We also consulted with frontline paediatricians in the busy general medical areas for recommendations regarding possible over-testing and over-treating that could be reduced, resulting in improved quality of care for our patients and their families. This resulted in our Sickkids Department of Paediatrics Choosing Wisely list of recommendations.
In the months ahead, we will endeavour to implement strategies to help clinicians make wise choices in these five scenarios. Physician champions have been appointed for each recommendation. They will collaborate with team members to communicate, educate, and create pathways to encourage evidence based practice. We will measure utilization of these tests and therapies and closely monitor patient outcomes. We should never forget that in Canada, despite all the background noise about the deficiencies, we as healthcare providers are privileged to have a remarkable healthcare system with many opportunities to exercise freedom of choice for our patients without oversight or restriction. It is incumbent on each and every one of us to make every effort to Choose more Wisely.