Stewardship and Choosing Wisely

March 4, 2016

Dr. Carl W. Nohr, AMA President

Dear Member:

Recently (February 17 President’s Letter) I wrote to you about the need for effective stewardship of the health care system by physicians. Many of you kindly wrote back to share your thoughts on how we might be more effective in that role and some of you mentioned Alberta-based activities leading in that direction. I would like to update you on a major effort here to increase appropriateness in our clinical decision-making.

Earlier this week I attended the Choosing Wisely Alberta Symposium. The Choosing Wisely movement was started in the United States by the American Board of Internal Medicine in 2012, growing out of stewardship principles similar to those about which I have written.

There are now Choosing Wisely Canada (CWC) and Choosing Wisely Alberta (CWA) initiatives. The adoption of CWA falls under the System-Wide Efficiencies and Savings Consultation Agreement that is part of the seven-year AMA Agreement with government. The campaign provides resources and materials to help physicians and patients have informed conversations about certain clinical conditions, affording the opportunity to avoid unnecessary tests and procedures. This contributes to safer care and better stewardship of resources.

At the symposium

Symposium sessions highlighted some of the CWA initiatives: blood transfusion; echocardiography; and Vitamin D testing. There were also sessions on the use of data in individual practices to make decisions, and the role of the AMA’s Physician Learning Program (PLP) in providing that kind of data. There were many posters about specific clinical topics, showing success in modifying clinical behavior.

It was interesting to hear about the formation of the Students and Trainees Advocating for Resource Stewardship group to give trainees a forum to develop ideas and promote the teaching of Choosing Wisely principles during medical school and residencies.

In order to reduce waste and decrease potential harm to patients, CWC is launching the 10 Million Challenge. This is a national initiative to prevent 10 million unnecessary tests and treatments by the year 2020. This is a goal worthy of our attention, as we seek to provide safe care and to be effective stewards over health resources.

Steven Lewis gave the first keynote address: “Winning Conditions for Uptake, Spread and Scale.” He spoke about change management and presented a list of strategies for success, including engaging doctors and patients, using supportive data, and applying behavioral economics principles to avoid ineffective incentives. He emphasized that discussion about appropriateness should focus on reduction of waste and harm, not rationing. He also addressed the cultural changes that are required.

The final keynote speaker was Paul Gallant: “Knowledge to Action: Changing the Dynamic between Patients and Providers: Engaging Patients.” It is clear that the roles of providers and patients are evolving. The medical profession is no longer the sole source of health information. Patients are diverse, but passive patients will gradually become a thing of the past. We need to recognize that every patient is unique, and that access to their own health data and relationships with providers are key to their participation in their own health care.

What next?

What is the future of Choosing Wisely? I anticipate that there will be further development of recommendations in a growing number of clinical areas. The PLP will continue to provide feedback to physicians on utilization, and interest in this service will increase. By providing utilization and outcome data to defined peer groups, unnecessary and unproductive variation will be reduced. There is a great need for this, especially if physicians are to be effective stewards in the health system.

With the work being done by practicing clinicians, and through introducing students to these concepts, there will be a cultural shift in the profession to greater stewardship. As for engaging patients in their own health, this is both inevitable and useful.

The following further resources are available on the AMA website:

I encourage each of us to learn more about CWA and CWC, to consider our own practice habits and to engage patients in conversations about best practices. Please consider the resources and materials available through CWC and CWA, and choose wisely!

As always, please let me know what you think. Email president@albertadoctors.org or leave a comment below.

Kind regards,

Carl W. Nohr, MDCM, PhD, FRCSC, FACS
President

3 comments

Commenting on this page is closed.

  • #1

    Fawzi Farhat

    Physician

    4:59 PM on March 04, 2016

    I think it is great topic, interesting learning apportunity for all of us and it is important step.
    You are right, known those concepts and working together along with patients will make this step very effective and I believe it will make positive changes in our health system.

  • #2

    Dr. Madhavan Das

    Physician

    9:35 AM on March 05, 2016


    Dr. Nohr,

    An excellent and crucially significant topic. At the PMI course we were casually chatting about the issue. Years ago when we didn't have Ct or MRI, the clinical skills were sharp enough to clearly locate a brain lesion, infarct or an active bleeding. Then the burr hole would most of the time confirm and then treat. Now the stroke patient brought to the ER / elsewhere will be lucky if you got a focused glance at by the duty doctor for a minute. Sent for CT, MRI, battery of tests !

    I used to work in a remote rural clinic, where there is not even a lab. More than 90% of the diagnosis needed to be made on history and clinical examinations alone. Now the trend is to "replace' the (lack of ) clinical skills with tests. This has become a culture as well. Working as a psychiatrist, I do not hesitate to examine a patient physically if that is appropriately indicated; especially with a holistic approach to patient. Medical education needs curricular change and a willingness to change the culture. Applied Clinical anatomy, Last's surface anatomy and several texts on physical assessment need to be heavily relied on.
    If there is a will there is a way - I think.

  • #3

    PremKumar Chengalath

    Physician

    3:57 PM on March 07, 2016

    AHS and Alberta Govt has to spend the dollars in public media and social media informing patients of these principles also, so it does not seem to come across as we as physicians are reluctant to comply with often times patient requests from ill informed sources.

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