Whenever it meets with physicians in their environment, the QMA has observed that many of its members are committed to improving care and services on a daily basis. Great initiatives are taking shape everywhere. Some of them should even be implemented or adapted elsewhere, but for this to happen, we need to know that they exist!
If you have set up a project that deserves more visibility or if you know of members colleagues who have done so, feel free to contact QMA. We would be pleased to showcase your achievements.
When providing harm-free care becomes a vocation
As soon as he started medical school, Dr. René Wittmer, currently an instructor in the Practising Wisely: Reducing Unnecessary Testing and Treatment program*, wondered about the hidden aspects of overdiagnosis. While he was doing community health internships, he was impressed by discussions on the importance of the population-based approach and the need to understand that, because resources are limited, they must go to the right place for the right people at the right time. He says that “this encouraged me and some colleagues to read up on some screening programs to ascertain how solid the supporting evidence was.” He concluded from what he read that overdiagnosis is inherent to systematic screening. Once he became aware of this complex issue, he decided to do more in-depth research and see how he could reduce the negative effects of overdiagnosis in his day-to‑day practice.
Dr. Wittmer is a local community service centre (CLSC) and university family medicine group (UFMG) family physician, and teaches residents and medical students. He has a varied practice that includes following up with patients in his office and tending to patients in home care settings, in blood-borne and sexually transmitted infection (BBSTI) clinics, and at Notre Dame Hospital.
Having developed a keen interest in combatting the problems of overdiagnosis and over-medicalization, it was quite natural for Dr. Wittmer to want to verify whether the program set up by the Québec Medical Association and the Quebec College of Family Physicians (CQMF) could meet his needs and fulfil his aspirations.
From participant to facilitator
When participating in a workshop, he quickly realized that he saw himself involved in this training. “I found that the message they were communicating was relevant and similar to what I had already been trying to communicate in my practice and to my medical residents. Nowadays, I continue to convey that message in my day-to-day activities,’ he explained.
Dr. Wittmer says that the Practising Wisely program is really distinctive, not only because it provides access to tools, but also because the program instructors are facilitators, first and foremost. “Many of the messages that participants retain come from the group discussions they have,” he explained. The moderators are there primarily to facilitate discussion and provide supporting evidence: “the participants draw their own conclusions,” he added. The idea is to encourage people to assess their practices and see how they can curtail overdiagnosis and over-medicalization.
“Everything is there in black and white,” says Dr. Wittmer. During the day, participants discover case studies they can use to assess how they use certain tools in a given situation and how to deal with obstacles that might arise in their day-to-day activities.
Tools that can be used to adopt new practices
Like the vast majority of physicians, residents and other clinicians participating in this program, Dr. Wittmer adopted new ways of doing things (see the results of the survey of workshop participants). “I had notions of overdiagnosis and how to curtail it, but I didn’t have tools to curtail it in my practice within a limited period of time,’ he explained. With the training, he discovered how to incorporate shared decision-making tools into his daily practice, particularly clinical decision-making tools and tools for explaining decisions to patients.
“Every day, I use Canadian Task Force on Preventive Health Care tools,” Dr. Wittmer pointed out. “This Canadian task force focusing on prevention and screening reviews literature and frontline clinicians’ recommendations for frontline clinicians. Their decision-making tools for the screening of various cancers are very well developed and explained in simple language.”
Family physicians also use the Absolute CVD Risk/Benefit Calculator posted online by James McCormack (and the French version was created with the assistance of Dr. Guylène Thériault, a member of the QMA Board of Directors). James McCormack, a professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver, is a passionate advocate of optimal use of medications and of evidence-based medicine.
His calculator can be used to estimate the risk of cardiovascular disease with the help of diagrams, smiley faces and sad faces. It also makes it possible to easily visualize the benefits and risks of a medical treatment, based on a patient’s personal information.
“We know that statins are a class of drugs that are frequently prescribed for cholesterol, and the advantage of this tool is that it can be used, in real time, not only to compare the effectiveness of a medical treatment, but also to see how effective the treatment is, compared with no treatment or alternatives, such as quitting smoking, changing one’s diet or increased physical exercise.”
Another benefit is that the calculator shows patients that treatment methods such as taking aspirin or vitamin supplements will not be beneficial in their case. “I turn my screen and allow my patient to see it. Together, we can calculate the intervention that will have the greatest benefit for their cardiovascular health, and the patient sees it in real time,” Dr. Wittmer explained.
International conference participants agree to take action
This summer, Dr. Wittmer and Dr. Guylène Thériault participated in the 6th international conference on Preventing Overdiagnosis, held in Copenhagen from August 20 to 22, 2018 (read the Overdiagnosis and overmedicalization: turning data into reduction article). He was impressed at discovering “this community whose existence I was unaware of and seeing that this interest in preventing overdiagnosis exists not only in Canada, but around the world. People agree that it is a major problem in our healthcare systems and that we need to take action.”
Although the issues appear to be the same in various countries, Dr. Wittmer believes it is still important to be able to quantify these problems that we are all aware of if we want to be able to take action. “We know, for example, that backache, which are one of the most frequent reasons for going to see a physician, are seldom pathologies for which it is necessary to take action because they are usually problems that people can solve themselves. However, based on the studies that participants have conducted in their communities, we could see evidence showing that opiates, which are not generally recommended for acute pain, are nonetheless overused, and that there is over-utilization of hospital resources for this type of problem.”
*The Practising Wisely: Reducing Unnecessary Testing and Treatment program is provided in Québec through a collaboration between the Québec Medical Association (QMA) and the Quebec College of Family Physicians (CQMF). This program was developed by the Ontario College of Family Physicians (OCFP).