Dialogue Volume 13 Issue 4 2017 - Page 42

PRACTICE PARTNER Hospital in Toronto. Partnering with pro- fessional societies, the team developed lists of tests and treat- ments, commonly used across specialties, that: Dr. Jobin Varughese • aren’t supported by evi- dence; and • c  ould expose patients to harm (from physical risks, to groundless concerns, to false positives). In April 2017, the Canadian Institute for Health Information reported that Canadians undergo more than one million medical tests and treatments every year that they may not need. While Choosing Wisely provides the inspiration, Practising Wisely offers support around the implementation. The Practising Wisely workshops (ocfp.on.ca/cpd/practis- ing-wisely) focus on real-life scenarios that mirror the work of primary care providers. The idea is to help family physicians shift the focus from looking for illness to sup- porting wellness. That hinges on the quality of doctor- patient communications. “Better conversa- tions build trust,” says Dr. Peter Kuling of Ottawa, the other Practising Wisely co-chair. Shared Decision-Making The goal is improved patient care based on shared decision-making. That can mean tests, or not, but it comes from a discussion instead of from an automatic response. Dr. Kuling, Assistant Professor of Family Medicine, University of Ottawa, says doc- tors worry about missing a medical problem. Tests provide a safety net. Yet that isn’t al- 42 DIALOGUE ISSUE 4, 2017 ways the right way to practise. “Over-inves- tigations yield all kinds of different pathways of investigations because you’ll find abnor- malities. But it’s wasteful of the system.” The very act of ordering tests, or learning results that aren’t actionable, can be prob- lematic for the patient. “It can cause anxiety if you feel you’re transitioning into a sick person,” says Dr. Kuling. Consider a patient with back pain. Sure, it’s easy enough to order imaging. That’s a tool. So is a dialogue. Patients have a chance to express their concerns, doctors can share their wisdom, and both parties can come to a meeting of the minds about next steps. “One of most powerful tools I have as a family doctor is a statement at the end of a visit. Like, ‘Your back is troubling you. You should improve, but if not or if you get new symptoms I’d like to reassess you. If every- thing clears up, cancel the appointment.’ If I see you in a month with new symptoms that have progressed, I’ll say, 'this is different, now we have to investigate.’ What we have now is continuity of care,” says Dr. Kuling. Such conversations can take more time, but not as much as you think. And not as much as the time needed for follow-ups for tests that weren’t warranted in the first place. “There’s an upside investment, because you reap benefits as you move along,” says Dr. Kuling. “Patients will trust you’ll have the conversation and not a knee-jerk decision.” The Diagnostic Cascade The Practising Wisely workshops have four modules, each centred on examples from ev- eryday practice: 1) harms and drivers of too much medicine (low back pain and ovarian cysts); 2) online resources to support prac- tice change (proton pump inhibitors and statins; 3) cancer screening; and 4) evolving