Empowering patients, saving the planet

Please note: This is the third article in a series on Planetary Health. See the first article on Introduction to planetary health in primary care and the second article on Environmental impacts of clinical practice: reducing unnecessary care.

Author

Dr. Ilona Hale MD, FCFP (biography and disclosures)

Disclosures: Received payments from Divisions of Family Practice, Cascades Canada, Therapeutics Initiatives, Health Quality BC, Interior Health Authority (in role as Medical Director for Climate Change and Sustainability), RCCBC, UBC, Alberta Pharmacists’ Association, and UBC Sauder School of Business Physician Leadership Program. None of these has influenced the information in the article or represent any potential conflict of interest. Received funding from Interior Health, Health Research BC, RCCBC, and UBC Department of Family Medicine. These grants were for work unrelated to the current article. Received sessional support for creating the Planetary Health in Primary Care Toolkit from the Division of Family Practice. Mitigating potential bias: Recommendations are consistent with Choosing Wisely and other standard practice guidelines.

What I did before

Although patient-centred care is a well-accepted principle of practice that has been shown to improve health outcomes and patient and provider satisfaction,^1,2 I hadn’t previously considered that providing patient-centred care might also be an important environmental action that I could take in my practice. “Green practice” had always meant turning off the lights, recycling and choosing reusable products, and I was not aware of the substantial environmental footprint of my clinical actions.

Although I was aware of the value of patient-centred care in theory, actually finding adequate time to have in-depth conversations with patients about the risks and benefits of various options for treatment and investigation often seemed difficult.

Patient-centred care also sometimes seemed to conflict with guideline driven, evidence-based medicine with its cookbook-style approach to different conditions. Typically, these guidelines incorporate implicit assumptions about the values and preferences of “average” patients. But not all patients hold the same values and, in my experience, some people are simply not interested in taking a lot of medications when the absolute benefit is small. I never felt I had the right to pressure patients to comply with guideline-based recommendations, but then I would feel embarrassed when colleagues would notice and attempt to correct my “mistakes”.

I often assumed that, unless patients said otherwise, they were happy with the suggested treatment plan. When patients were “non-adherent”, I would assume it was due to cost, side effects or a lack of understanding.

What changed my practice

While exploring ways to reduce the environmental impact of my practice, I learned that it is the clinical decisions for testing and treatment that account for most of healthcare’s substantial footprint (rather than facilities and travel), and that much of this is unnecessary (30%) or unwanted. Reducing care that patients didn’t even want seemed like a really important opportunity. Patient-centered care is actually one of the principles of environmentally sustainable practice³ because nearly everything we do in medicine carries a carbon footprint, except talking with and listening to our patients. When patients are well-informed, they generally choose less and more appropriate care.⁴ Shared decision-making (SDM) tools can help patients better understand the absolute risks and benefits of different testing and treatment options, and allow patients to decide what is right for them. In one study, when patients were better informed, the demand for major elective surgeries was reduced on average by 20% compared to usual care: 40% for benign prostate disease, 20% for hysterectomy for menorrhagia, 20% for stable angina and 30% for herniated discs.⁴ Reassuringly, for a procedure where the medical evidence supported surgical intervention (spinal stenosis), patients who were well-informed were 40% more likely to choose surgery.⁴ In another study, SDM resulted in 48% fewer inappropriate antibiotic prescriptions for upper respiratory tract infections.⁵ In one UK study, 73% of patients reported a desire to be involved in medication decisions, but only half of patients felt they were.⁶ Many studies have found that about 50% of patients don’t take their medications correctly, and 30% don’t take them at all,⁷ leading to considerable waste, risk and expense. SDM has been found to typically add only 2.6 minutes to a visit⁸ and is rewarded downstream by less time spent following up on tests or treatments that were never wanted, or needed, in the first place.

Mulley has described the concept of a “preference diagnosis”; once the medical diagnosis has been made, we then need to understand what this means to patients and how they would like to proceed.⁴ We often miss this step, making many assumptions about our patients and what might matter to them. For example, in one study of breast cancer patients, it was found that doctors believed 71% of patients prioritized keeping their breast, when in fact only 7% did.⁹ Furthermore, doctors believed that 96% of patients scheduled for chemotherapy considered living as long as possible their top priority, when the actual figure was 59%.⁹ These assumptions can lead to care that is inappropriate, unwanted and costly to patients, the system and the planet. Asking patients, “What matters to you?” has been shown to improve outcomes and efficiency, decrease formal complaints and increase provider understanding, connection and meaning in their work.¹⁰ Particularly near the end of life, we often expend enormous effort and resources in hospital and ICU care, when 80% of older adult patients actually prefer a less aggressive, more comfort-oriented end-of-life care plan.¹¹ Medicine may be the one field where we could improve outcomes, save money, time and the environment, by simply giving patients what they actually want.⁴

What I do now

Knowing that I can improve patient care and lighten my carbon footprint by using these principles has provided me with extra motivation to use many of the excellent shared decision-making tools available more regularly (see resources below). Most patients are interested in seeing how their own personalized risk factors and treatment choices affect their risks. They are often surprised at the very small absolute benefit of many of the tests and treatments we commonly use, especially when compared to lifestyle factors. Empowered with this information, many patients choose to forgo low-value medications or investigations. When I refer to specialists, I share results of these discussions and the patient’s preferences to avoid confusion. Instead of simply thinking of patients as “non-compliant”, I try to take more time to understand “What matters to you?” and sometimes identify misunderstandings that can be addressed. In other cases, when reviewing the evidence together, I realize that their choice not to follow the standard recommendations is reasonable for their particular situation (e.g., limited benefit, multiple co-morbidities, frailty, etc.). I try to initiate serious illness conversations early to avoid excessive, inappropriate end-of-life intervention and discuss discontinuing long-term prevention medications for patients with limited life spans.

I am happy to know that by empowering patients, I can not only provide better care but also reduce environmental impacts and unnecessary burdens on the system.

Resources for health-care providers

• Serious Illness Conversation Guide

Shared decision-making tools:

• PEER Simplified Cardiovascular Decision Aid
• PEER Diabetes Medication Decision Aid
• PEER Simplified Chronic Pain Guideline
• Mayo Clinic Bone Health Choice Decision Aid
• Canadian Task Force on Preventive Health Care Screening Tools

Patient resources:

• Choosing Wisely Canada Patient Resources

References

1. Patient engagement. Geneva, Switzerland: World Health Organization; 2016. (View PDF)
2. Paterick TE, Patel N, Tajik AJ, Chandrasekaran K. Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017;30(1):112-113. doi:10.1080/08998280.2017.11929552 (View)
3. Mortimer F. The sustainable physician. Clin Med (Lond). 2010;10(2):110-111. doi:10.7861/clinmedicine.10-2-110 (View)
4. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012;345:e6572. Published 2012 Nov 8. doi:10.1136/bmj.e6572 (View)
5. Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012;184(13):E726-E734. doi:10.1503/cmaj.120568 (View)
6. Weir KR, Ailabouni NJ, Schneider CR, Hilmer SN, Reeve E. Consumer attitudes towards deprescribing: A systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci. 2022;77(5):1020-1034. doi:10.1093/gerona/glab222 (View)
7. Hamilton JE, Blanco E, Selek S, et al. Patient and provider perspectives on medication non-adherence among patients with depression and/or diabetes in diverse community settings – A qualitative analysis. Patient Prefer Adherence. 2022;16:1581-1594. Published 2022 Jun 30. doi:10.2147/PPA.S328785 (View)
8. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4(4):CD001431. Published 2017 Apr 12. doi:10.1002/14651858.CD001431.pub5 (View)
9. Lee CN, Dominik R, Levin CA, et al. Development of instruments to measure the quality of breast cancer treatment decisions. Health Expect. 2010;13(3):258-272. doi:10.1111/j.1369-7625.2010.00600.x (View)
10. Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ. 2002;325(7366):682-683. doi:10.1136/bmj.325.7366.682 (View)
11. You JJ, Dodek P, Lamontagne F, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ. 2014;186(18):E679-E687. doi:10.1503/cmaj.140673 (View)

Vote

Please indicate how this article will change your practice:

Empowering patients, saving the planet

• I disagree with this approach
• I will consider changing my practice, but need more information/time
• I will likely change my practice
• I will definitely change my practice
• I already do this

View Results

 Loading ...