From engagement to collaboration, physician participation is essential in ensuring the successful implementation of Choosing Wisely Canada recommendations in Manitoba, and further identifying new opportunities for resource stewardship within our provincial health care system. Our growing list of local Clinical Champions proudly represent the Choosing Wisely vision throughout Manitoba.
Dr. Christine Polimeni, MD, CCFP – Family Physician and Vice Dean Continuing Competency and Assessment- University of Manitoba
Choosing Wisely is important for the sustainability of health services, not just for my patients, but for all Manitobans. We only have so many resources and I want to ensure we’re allocating tax dollars to the highest value services my patients really need. I am a witness to this on a daily basis, appraising my actions while advocating for the best care for my patients; so I feel a duty to “Choose Wisely” so my patients will get the care they really need, now and into the future.
Communication is critical in making this initiative a reality. Meeting the expectations of our patients needs to be managed in a socially accountable manner by educating and setting a behavioral standard at each clinical encounter. Any day that I can pass this information on to one of my patients is a good day in clinic. Any day that they can carry that sentiment forward to others is an even better day!
Fortunately in my practice, I am starting to see patients who are becoming wise to unnecessary drugs and diagnostics. A great example is the work up for acute lower back pain. This is a great opportunity for a one on one discussion on the topic of unnecessary x-rays, CT’s and MRI’s. I will often ask my patients about their expectations of the outcomes of a specific test. If they request a CT scan, do they worry about the radiation exposure, are they concerned about their condition worsening, what do they think the harm is in delaying an exam, what red flag symptoms should they be aware of? It gets us to the heart of their expectations, and often we can agree that we don’t need to do the test. We can then move onto a management plan, which gives a feeling of satisfaction.
Communication is also moving forward between our medical experts. During our CPD sessions, conversations about social accountability are occurring more frequently. Scientific planning committees are now integrating Choose Wisely tools at many of our educational events and physicians, both new and established, are utilizing these resources that will help support them in their daily clinical encounters. Unfortunately, we don’t get through to every patient, some still advocate for that test or prescription, but the tools that Choose Wisely Manitoba is developing can strengthen our role as “medical expert” and offer us a tool kit to draw from and allow us to further open up those conversations. We will, however need to move beyond the paper reference materials- utilize the waiting room for educating and leverage technology through social media and patient information resources. I believe we can educate on their terms and must influence on our terms.
Dr. Alex Singer, Associate Professor, University of Manitoba
I think Choosing Wisely matters to every patient I see as it refocuses me to think carefully when making treatment decisions. As a physician, I accepted the obligation stated in the Hippocratic Oath to “do no harm” and fundamentally I think that is what Choosing Wisely is about. If physicians provide unnecessary or extraneous care, we will eventually harm someone – no diagnostic test, procedure, or medical treatment is risk free. Not only do we need to know when to do provide certain potentially life-saving tests and treatments, but equally important is knowing when not to perform those same interventions if doing so might actually harm the patient given different circumstances. Importantly, the Choosing Wisely campaign doesn’t try to tell us “never” do something, but rather encourages and supports us in using our clinical judgment and evidence-based patient centered rationale to make the best decisions. Typically medical education encourages us to be thorough, which is generally a good thing, but taken too far, we risk failing to be judicious when it is appropriate for our patients to do less.
I appreciate Choosing Wisely Manitoba for keeping us on top of the evidence and challenging us to question what we do. I think it’s useful that these recommendations are convenient, concise, peer-reviewed and evidence-based. In my practice, we’ve noticed that once you get engaged in thinking about the Choosing Wisely recommendations there is a collateral benefit – even if you haven’t memorized all the specific recommendations, you find yourself naturally questioning and more likely to modify your clinical practice for the patient in front of you. It also gets us thinking about other quality and efficiency improvements in our clinic that may be more “lean” than “choosing wisely”. One of the challenges or risks related to the advancement of the evidence-based medicine paradigm is that we seem to be encouraged to follow algorithmic protocols that can take discourage the heuristic interaction between patient and physician. Choosing Wisely encourages us to be judicious interpreters selecting the interventions that are right for our patients and being more cognizant of our role to treat each patient as an individual and not apply tests and treatments indiscriminately. Personally, I think it helps me be a more mindful doctor ensuring my care leads to truly beneficial outcomes in my patients.
Prescribing antibiotics is a good example; if we blindly dispense these powerful medications for every potential infection, we lose sight of what is best for each individual patient; perhaps I should not be worrying about the cough in a 5 year-old as much as an 70 year old with COPD.
My research and clinical work overlap in the clinic where I work. I’m privileged to work in a place that has been willing to change our practices based on our own EMR data and other benchmarks for some key indicators. Interestingly, it is giving us a new perspective on practice outliers and practice change, but also on how we need to make system changes that support us doing the right things, and help us avoid doing unnecessary things.
Dr. Jose Francois, Head, Department of Family Medicine, University of Manitoba
Medical Director, Family Medicine, Winnipeg Regional Health Authority
I’ve been involved with Choosing Wisely Manitoba since its beginning, and I’m pleased to be considered a Clinical Champion. Beyond each of the specific recommendations, we are encouraged as physicians to question the things we’re doing on a daily, patient-by-patient basis. We’re challenged to reflect on the evidence and ask ourselves if what we’re doing is appropriate – it builds an almost automatic reflex reaction to everything we do; after all, not everything we do is beneficial, and we should be questioning the real clinical needs and risks for our patients.
I’m particularly interested in choosing our therapies wisely and a few of my pet interests include: medications typically prescribed for long periods of time (such as proton pump inhibitors), polypharmacy, and the long term value versus negative impacts and side effects of all medications we prescribe for our patients.
In my own specific practice, I am keen to participate and encourage all my colleagues to take quarterly medication reviews seriously and am especially interested in over prescribing and long-term use of antipsychotics, sedatives and the multi-pharma cocktails many of our geriatric patients. I recall one particularly elderly patient on multiple medications, including 3 different antipsychotics – she was barely ambulatory and virtually comatose. After our team case review, we designed a step-down regimen that ended with 1 medium dose antipsychotic and many fewer drugs; she became more mobile and cognitive – the family couldn’t believe how it was like she had been returned to them.
Often our medical team and the family fear the impacts and risks of reducing these medications, but in one of our units we were able to free up nursing time by reducing the number of medication “passes” – reducing the cycle and frequency of medication distributions to patients, and offsetting the time they were able to spend with each patient and support step-down regimens. Knowing that their loved one will have more attention is very reassuring to families who really want their granny not to be medicated so heavily, but fear change even if granny could be returned to them because they think “she’s doing so well”.
Choosing Wisely Manitoba has challenged, encouraged, and enabled us to examine many of our clinical practices – and I believe we are improving quality, improving the health system, delivering better care, and ultimately reducing wait times and saving health care dollars.