Dr. Craig Goldie (biography and disclosures)
What I did before
As a family physician trying to embrace family medicine competencies (CanMEDS-FM), I have struggled in my role of “gate-keeper”. I feel physicians have a responsibility to be judicious with ordering investigations and treatments, not only for the ethical principle of primum non nocere (first, do no harm) but as well the bioethical principle of distributive justice: the appropriate use of limited resources to benefit the greatest number of patients. Despite our best intentions, there are still large numbers of our patients who receive treatments and investigations that lack evidence of benefit, or, sometimes, even cause harm.
This is a complex problem that has to do with a number of issues: rapid changes in research and guidelines, increased patient volumes, and a trend towards patient requesting their own tests or treatments.
First, it is very challenging to keep up with best evidence. We are lucky to have the BC Clinical Practice Guidelines but they do not address all topics. The amount of new medical literature is staggering and it is impossible to read and appraise it all. Many of us have been taught things which are no longer considered best practice but we continue to use that knowledge to inform our practice as we are unaware of the new information. In other cases, guidelines are conflicting or unclear, with weak evidence, so we do not know how best to interpret these for our patient population.
Second, in busy family practice offices, with 10-15 minute appointments, we are sometimes tempted to do what is easier such as order an investigation or write a prescription, despite our awareness that it may not be necessary. I have often found taking the time to explain why something is not going to be beneficial is both more time-consuming and does not always satisfy the patient, which can lead to fatigue and frustrating work days for me.
Finally, today’s patients are more empowered than ever and have access to immense amounts of literature online. This is generally a good thing, in that they are more invested and aware of their own health and recovery. The downside is the increasing rates of patients who come in with specific requests for tests, interventions or treatments. We have all experienced patients requesting MRIs for non-specific aches and pains, antibiotics for colds, and non-indicated blood tests that they heard about on TV or from a friend. Addressing this is time-consuming and can leave both physician and patient unsatisfied.
What changed my practice
I have recently completed extra training in palliative care which has shown me first-hand some of the harms that we can do, with best intentions, by excess testing and interventions that do not change management or provide quality of life or are not within the goals of the patient.
Through my training I read that the American Academy of Hospice and Palliative Medicine had provided 5 recommendations regarding palliative care to a website, called Choosing Wisely, http://www.choosingwisely.org. It is a resource provided by the ABIM Foundation (Advancing Medical Professionalism to Improve Health Care) and is focused on encouraging physicians and patients to think and talk about medical tests and procedures that may be unnecessary or could cause harm. Virtually all of the American medical societies, such as the American Academy of Family Physicians and American College of Radiology, have provided lists of 5 things that physicians should question prior to recommending a test or intervention.
A large part of the site is geared to physicians, including the lists as mentioned above. These lists are written in simple language and are very quick and clear to read. They cover most areas of practice and, while some are directed towards specialists in a specific field, many are very relevant to family physicians. The lists include references for further reading and the lists are frequently expanded and updated.
The other part of the site includes patient-friendly resources covering topics such as allergy tests, bone density, imaging, paps, antibiotics for sinusitis etc. Patients can access the website directly or they have handy printable handouts that you can have in your office or print out for your patients.
What I do now
Many of the recommendations on the website were, fortunately, things I already knew. Others were new to me and I have been able to implement them in my practice with confidence and justification. I find it helpful to have the recommendation and references in ‘black and white’ to show patients and, if necessary, print them out and provide them a copy. I keep some patient print-outs on the common topics such as antibiotics in sinusitis and imaging for low-back pain.
It was also helpful to be able to see how these recommendations are explained in a natural language that would help the patient understand the rationale for not pursuing a test or intervention. I have found myself using a lot of the same wording and sentences from this website when counseling patients or family and say things like “the gastroenterological society recommends we adjust your acid suppressing medication to the lowest effective dose”. I can bring up the bookmark and show them the official recommendation quickly, which can help the visit proceed faster.
I have found this resource to be an easy way to keep up-to-date on recommendations of things I shouldn’t do. It has given me confidence in many of my decisions and provided me with new recommendations on avoiding unnecessary medical tests or interventions which could lead to harm in my patients. It has helped to give me some specific words or phrases that patients will understand, and it has given me some more ‘ammunition’ to back up decisions in the case of demanding patients. It has also allowed me to more quickly access the recommendation and references to show to my patients, as the website is very easily navigated and no account or login is required.
I still struggle at times with my role as a “gate-keeper” of the health care system, but this resource has helped me become more of an expert in family medicine, a better communicator, professional and health advocate for my patient. Not all patients are happy when I decline to order a test or treatment, but I am comfortable in knowing I am providing the best care and hopefully reducing iatrogenic harm in my patients.
As a caveat, please note that Choosing Wisely is US-based and based on US medical associations, therefore some of the recommendations are not in complete agreement with our own guidelines – either provincial or nationally. Many of the patient material include costs of investigations which are not relevant to patients in Canada (but should be to us). As always, these suggestions must be placed into the context of your patients and your own clinical decision making.
I hope you find this reference useful and will help you provide better care for your patients and have confidence when you decide the best intervention may be no intervention but rather simply reassurance.
- CanMed-FM roles – http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf
- Choosing Wisely – http://www.choosingwisely.org