Dialogue Volume 13 Issue 4 2017 - Page 43

PRACTICE PARTNER the annual physical to become a periodic health review (poly pharmacy in the elderly and over-monitoring for diabetes). The workshops were launched in 2011, before Choosing Wisely was established. Dr. Jennifer Young, who helped to develop the original curriculum, says the course has been redeveloped since to enhance its impact and address all seven of the CanMEDS physician roles (medical expert; communica- tor; collaborator; manager; health advocate; scholar; and professional). Participants earn professional development credits. In November 2017, the OCFP held its in- augural Practising Wisely Day in Toronto, of- fering a full day of learning around reducing over-prescribing, over-imaging, over-screening and over-monitoring. One test can lead to another, increasing risks and patient unease. Dr. Young calls it “the diagnostic cascade”. Framing the discussion around tests isn’t a matter of doctors saying “we must do this” or “we shouldn’t do this”, but of talking about evidence and grasping the patient’s mindset. Take something like prostate cancer. The Canadian Task Force on Preventive Health Care looked at PSA tests. They found that the potential small benefit is outweighed by the possible significant harms of the screen- ing and associated follow-ups (like biopsy or treatment complications). The Task Force says men should know that screening may result in additional testing if the PSA level is raised. Among men screened with the PSA test, the risk of dying from prostate cancer is 5 in 1,000; among those not screened, that risk goes to just 6 in 1,000. Different doctors have different outlooks on PSA screening. So do different patients. What’s the right thing to do? Talk openly about the disease, symptoms, risks and how the patient is feeling. Is he stressed because he wants the test or because he doesn’t? Does he know other people who’ve had the screen- ing, and is that influencing him? Whatever the variables, the doctor is there to help guide, not dictate. “I’m the advisor, I work for the patient, so it’s a shared decision,” says Dr. Kuling. As Dr. Varughese explains, in