practice partner
What To Do
When You
Do Nothing
Help patients understand
when tests and treatments
are unwarranted
DOC TALK
By Stuart Foxman
Dr. Kimberly Wintemute
photos: D.W. Dorken
photo: istockphoto.com
“I
want an MRI.” Frequently, that’s how
patients have greeted Dr. Kimberly Wintemute. Before even disclosing the reason
for visiting, these patients have already diagnosed their pain and are clear on the course of action.
That’s a challenge in many patient encounters, says
Dr. Wintemute, Medical Director of the North York
Family Health Team. Patients may have mistaken assumptions about the investigation or drug that should
come next. With low back pain, for instance, Dr. Wintemute will often determine that there’s no dangerous
cause or need for imaging.
“After forming my differential diagnosis, part of my
job is understanding what the patient thinks about this
problem,” she says. “What are their expectations, and
how can we come up with a plan that will be effective
and the best use of resources?”
As the Choosing Wisely Canada (CWC) campaign
notes, more care isn’t always better. What happens when
the interventions patients hope for aren’t warranted?
More broadly, how do you avoid making patients feel
like you’re doing nothing? We asked four doctors and
one patient involved in CWC about the best ways to
have that conversation.
Easier to say yes
When patients expect any number of next steps, from
an antibiotic to an ECG, any other result can disappoint. Yet saying “yes” when you shouldn’t, or saying
“no” without an explanation, is counterproductive.
Dr. Barbara Liu, a consulting geriatrician at Sunnybrook Health Sciences Centre in Toronto, understands
why doctors might be tempted to agree to something
that’s unnecessary. It’s quicker and easier. “Providing
counselling, education and support takes more time
and energy,” says Dr. Liu. “But why would you feel you
have to take the easier way? Are you focusing on your
needs or the patient’s?”
Dr. Carter Thorne, a rheumatologist at Southlake Regional Health Centre in Newmarket, says some patients
who had a bone density test the year before will request
another. Maybe they’re worried about fractures because
a relative was prone to then.
In this case, repeating the test so soon is unnecessary.
What patients deserve to hear is 1) rationale for decisions; and 2) alternatives. So Dr. Thorne will note the
best evidence on when and why (i.e., risk factors) bone
density tests should occur. He might record a timeframe
for a next test, but reinforce that there’s no value in do-
Issue 1, 2015 Dialogue
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2015-03-19 11:18 AM