Practising wisely: Dr. Vincent Demers’ story
Family physician and vice-president of the QMA, Dr. Vincent Demers provides care at home for geriatric patients who are losing their autonomy, in addition to treating vulnerable patients at the GMF ProActive Santé Neufchâtel and working with the SPOT community and teaching clinic. On May 2, 2018, he participated in the Practising Wisely: Reducing Unnecessary Testing and Treatment program. This training is a collaboration between the Québec Medical Association (QMA) and the Québec College of Family Physicians (CQMF). The six-hour course uses concrete examples (PPIs, screening, lower back pain, etc.) to discuss overprescription, overdiagnosis, overtreatment and excessive medical imaging. Dr. Demers agreed to talk to QMA Info about his participation in this program.
QMA INFO: Why did you decide to register for this course?
Dr. Demers: Medicine is evolving rapidly. I started my practice in 2004, and many guidelines have changed since then. They often contradict each other, leading us to change the recommendations we give our patients and creating confusion for them. I decided to register for this course mainly to acquire the tools to better address the needs of my patients who ask for screening tests and annual exams that they are used to getting, but which are no longer recommended.
QMA INFO: How did you learn about overdiagnosis and overtreatment? And how did they impact your practice?
Dr. Demers: I often thought that I prescribed some tests to avoid missing a serious but unlikely diagnosis, or because it was expected from me by patients or colleagues to be a good physician. With experience, I realized that many tests or procedures could cause more damage than good to patients and increase their anxiety, without even getting into how the cost and use of resources affected our suffering health care system. The discussions and questions over the last few years about the appropriateness of certain screening, such as for prostate cancer with the PSA test, opened my eyes to this problem. There is still a culture in medicine to look for anomalies among asymptomatic patients and to attempt to treat them before symptoms appear, but without ensuring that this will have a real positive impact on mortality or morbidity.
QMA INFO: What are the obstacles for a practice that is concerned by overdiagnosis and overtreatment?
Dr. Demers: On the one hand, it is sometimes necessary to go against some practice guidelines developed in the US or expert recommendations that can be biased and funded by the pharmaceutical industry. We also have to be aware when we attend expert conferences. On the other hand, we have to break free from the culture of tests and exams that we have established among physicians and patients, and always ask ourselves about the appropriateness of each of our investigations and procedures. This requires time and energy, which is not easy in our practice conditions where we always seem to be rushing, but it is essential. I have noticed, for instance, that before recommending our patients to a specialist, more and more often there is a blind requirement for preliminary tests, even if we feel they are not appropriate. We need to get back to basics by involving and enlightening our patients on each of our decisions that concerns them, because often they don’t ask for that much and it’s more to reassure ourselves, as physicians, that we overdiagnose and overtreat our patients.
QMA INFO: Did you discover tools or ways of doing things that will help you in your practice?
Dr. Demers: The Choosing Wisely Canada initiative, the Canadian Task Force on Preventive Health Care, some Web sites such as TheNNT, and a number of tools from INESSS help me to think about my practice better. There is also information for patients, which helps guide our discussions better and debunk the myths.
QMA INFO: How do you broach the issue of overdiagnosis and overtreatment with your patients? Has that evolved in the last few years?
Dr. Demers: I explain to them that medical recommendations evolve, which is a sign of a critical and scientific approach. I take the time to explain the risks and benefits of the proposed tests. I sometimes use existing tables that show how many people out of 1000 will benefit from a test or procedure, and on the contrary, how many will suffer adverse effects. Among patients who have been using drugs for a long time, I periodically review with them the need to continue medication and I try to deprescribe the ones that no longer have a clear benefit. I have been much more aware of these issues in the last two years than before, I think the wind is changing in the medical culture.
QMA INFO: What do you plan to change in your practice after taking this course?
Dr. Demers: I have already started, I am trying to get back to basics, at the clinic, with the questionnaire and the physical exam, to consider the implications of each of my interventions and to get patients more involved in the decisions. The main obstacle is still the amount of time that that requires.
QMA INFO: Would you like to add anything else?
Dr. Demers: The course was excellent!