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-
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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