Canadian champion visits New Zealand
On 18 March, Dr Peter Kuling presented to senior health professionals about his Choosing Wisely Canada work. The meeting was coordinated by Choosing Wisely New Zealand and hosted in Wellington by the New Zealand Medical Association.
Dr Kuling is a Choosing Wisely Canada champion and advocate, and has an interest in shared decision making to prevent overdiagnosis, over screening and over treatment. He is concerned about the harm caused to patients of “too much medicine”.
For his first 20 years of practice Dr Kuling was based in northern Saskatchewan, working in ‘full spectrum family medicine’ there and later in Ottawa. He is now teaching at the University of Ottawa where he is Assistant Professor Family Medicine.
He describes Choosing Wisely as his ‘new passion’ over the past few years.
“Choosing Wisely is our national voice for reducing unnecessary tests and treatments; it has been adopted or endorsed in all provinces in Canada.”
He says while Choosing Wisely is a relatively new movement, it has gained momentum quickly.
“Choosing Wisely started in the United States in 2012 and was introduced to Canada in 2014. There are now over 20 countries engaged in it, including New Zealand.
“Choosing Wisely Canada is primarily clinician-led and is not affiliated with any specific college or with Government. It was started with a grant from the Canadian Medical Association. It is very much a bottom-up movement – evidence-based but very simple in the way that evidence is applied.”
Dr Kuling says the Choosing Wisely ethos is about having the professionalism as a physician to practice in a way that is cognitive and evidence-based, while still doing the right thing for the patient.
“It is about thinking ‘what test do I have to do that will change the management and help this patient?’ If the test doesn’t help, or the drug doesn’t help, don’t use it.”
In Canada, over 70 medical associations and societies support Choosing Wisely, and there are 300 plus recommendations.
“We are involving dentists, pharmacists, nurses, all the health professionals – it’s not just physicians any more. We are trying to move beyond lists. They are a good starting point but we have to get better.”
Effectiveness of Choosing Wisely
In 2016, a survey was undertaken to gauge clinician awareness of Choosing Wisely Canada. It found:
• 88 percent of physicians who responded were aware of Choosing Wisely
• 42 percent were using lists on a daily basis
• 66 percent said they needed tools to help patients make an informed decision
• 48 percent said they needed more tools themselves to make decisions.
A survey of consumers in 2017 found:
• 30 percent of respondents said their doctor had recommended a test or treatment they (the consumer) didn’t feel was necessary
• 27 percent took the test recommended, without discussion with their doctor
• 50 percent asked why the test was necessary
• 23 percent ignored the doctor’s advice.
Dr Kuling says that, although awareness of wise use of interventions and testing is growing, there are still areas of challenge.
“In Canada we still have problems with things like unnecessary CT scans, screening mammography and prostate screening. For example, 30 percent of ED patients in Ontario and Alberta with low-risk minor head trauma have a CT head scan. In Ontario, 23 percent of inpatients with delirium had a potentially unnecessary head CT scan. And our benzodiazepine use in seniors is still high – we have some provinces where the rate is increasing.”
Campaigns for the public and health sector
Dr Kuling talked about several Choosing Wisely campaigns underway in Canada.
More is not always better
This consumer campaign has a number of visual representations of why more isn’t always better, as well as a video for waiting rooms. It aims to:
• promote the message that in medicine as it is in life, ‘more is not always better’
• educate patients about when they might need a particular test or treatment, and when they don’t
• encourage patients to talk with their doctor about unnecessary care.
Dr Kuling says that ‘hot dog’ poster is in his office, and the offices of many family physicians. It is accompanied by four questions consumers are encouraged to ask their family physician.
‘Do it yourself’ campaign
While public campaigns are very valuable, we also need to see behaviour change in physicians, says Dr Kuling.
“How do you actually implement change? We know in the spectrum of implementation that patient and clinician education are low leverage interventions. At the high end of the scale is the hard coding, where you actually have order sets. As an early doctor, I know I ordered many more tests than were needed when patients were admitted to hospital.
“But now, if we have medical directives and clear order sets that, for example, eliminate doing an ECG on everybody who comes into the hospital, this will make an incredible difference for the system. If you order a CT scan, you have to meet criteria. If you don’t meet those criteria, you must phone the specialist to get the CT scan.
“In the middle, we have to start moving towards quality improvement projects. We have to start thinking of Choosing Wisely as a good forum to do quality improvement.”
Choosing Wisely Canada has developed ‘do it yourself’ toolkits based on different areas of intervention or treatment.
“These are toolkits authored by practitioners and peer reviewed. They are living documents that continue to be revised. The toolkits are key ingredients to make a change intervention.”
Students and Trainees Advocating for Resource Stewardship (STARS)
Dr Kuling also talked about the STARS programme – an initiative that started in Canada and which has spread to other provinces and internationally.
“Students are really embracing this as an opportunity right from first year to be very cognitive and deliberate in their investigations; to challenge their tutors; to challenge their case-based-learning faculty. I think the reason STARS has taken off in Canada is because it received an overwhelming endorsement from the deans of our medical schools.
“Deans sponsor students in first and second year, and those cohorts move through each of the years championing Choosing Wisely principles. This year for the University of Ottawa alone we have at least 15-20 applications out of each of the years for each of the cohorts.”
He says students go to the annual Choosing Wisely meeting, where they have a full day on leadership, advocacy and evidence-based medicine.
“They get very enthused and form networks. There is a real buzz created between all the different medical schools.”
Students then return to their universities and must work on a Choosing Wisely initiative. Projects have included:
• the development of Choosing Wisely lists
• the development of interest groups, with meetings and speakers
• awareness or campaign weeks
• undertaking a Choosing Wisely needs assessment
• starting journal clubs
• holding student events.
“These students are having a real leadership role. They have met with members of parliament, and been covered by the national press. Resident doctors are also doing their own lists.”
Behavioural change for family physicians
A current focus for Dr Kuling is a behavioural change educational venture for family physicians.
“My challenge is mid- and late-career physicians who say, ‘I’ve always done it this way, I’m not about to change’. We have developed a special professional development programme, “Practising Wisely”, that was launched in Ontario by the college of family physicians which has now spread across the country, with train-the-trainers in each province.
“We have a set of modules that cover things like over-imaging, over-prescribing, over-screening, and changing the mindset about annual health check-ups. There is also a big emphasis on de-prescribing; taking away drugs rather than adding extra ones.”
More information about the Choosing Wisely Canada campaign can be found at choosingwiselycanada.org.
New Zealand Choosing Wisely facilitator Sue Ineson says in this country, 31 medical colleges, specialty societies and health practitioners’ associations are linked to the campaign, and over 154 lists of tests, treatments and procedures that should be questioned have been developed.