Choosing Wisely Canada National Meeting
The QMA was in Toronto on April 23 to attend the Choosing Wisely Canada National Meeting. It was an inspiring event that showed that this national and local campaign is a success. Besides recommendations made by the different Canadian learned societies participating, the teams that implement projects in the different provinces also bring about improvements in patient care and health care systems. For those who could not attend, the key messages are below.
1) The fear of being sued for not doing a test is a myth
When physicians in Canada, but also elsewhere in the world, are asked why they do or order so many tests, most often their first response is “out of fear of being sued.”
“Never has a physician been sued for not having done a test. However, many physicians have been sued for doing tests and not following up on them,” pointed out Dr. Hartley Stern, Executive Director/CEO of the Canadian Medical Protective Association in his closing presentation at the meeting. In short, following the recommendations of Choosing Wisely Canada does not create any problems in terms of professional liability.
It is a stubborn, undocumented myth from the legal aspect that persists within the medical profession without reason. Already in August 2017, as part of the international Preventing Overdiagnosis conference in Québec City, the QMA had organized a workshop on this topic to reassure participants. One year later, the Executive Director/CEO of the CMPA confirmed that “there is no risk in following the recommendations of Choosing Wisely Canada. If there is a risk, it is more likely in doing tests that we know are unnecessary and to forget to do the follow up.”
2) Lack of Québec government support for the Choosing Wisely Canada campaign
At the meeting, many observers noted the Québec government’s inactivity and lack of support for the Choosing Wisely Canada campaign. At the opening of the meeting, it was stated that the federal government and all the provincial governments were partners in Choosing Wisely Canada, except for Québec where it is the medical association, the QMA, that is the communication channel between the French-language recommendations and the local partner. In truth, the QMA took on these roles because the Québec government failed to commit! The QMA is now responsible for the French-language component of the campaign and is the coordinator of Choosing Wisely Québec.
3) The quality of care includes appropriateness
A quality health care system must be safe, efficient, effective and fair, in addition to providing care within reasonable timeframes and that is patient-centric. The Choosing Wisely Canada campaign deals with all these elements of quality control.
- Safe: unnecessary tests or procedures cause damage
- Efficient and effective: waste reduces the system’s performance
- Fair and within timeframes: while some people undergo unnecessary tests, others wait
- Patient-centric: unnecessary tests or procedures are contrary to the well-being of patients
4) Using administrative data to define intervention targets
Dr. Joshua Tepper, President and Chief Executive Officer of Health Quality Ontario, made a strong impression with the audience. He explained that in his province, researchers used administrative data from the health care system to know which procedures to target. They compare the Choosing Wisely Canada recommendations with the percentage of overdiagnosis or overtreatment and the resulting costs. This gives them the scope of a problem and its cost. They can then guide decision-making to know when to intervene or not.
5) Reducing unnecessary tests and treatments in health care
In 2014 when it was launched, the purpose of the Choosing Wisely Canada campaign was to help clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective care choices.
At the 2018 meeting, participants decided to put more emphasis on the actions aimed at reducing unnecessary tests and treatments in health care.
Naturally, Choosing Wisely Canada will continue to equip clinicians and patients to help them have discussions about unnecessary care, but also plans to put more emphasis on supporting initiatives to implement measures aimed at reducing inappropriate care. This decision led to the creation of an “implementation research network”.
6) The third era of medicine
A very interesting presentation by Dr. Dee Mangin, Professor and David Braley Nancy Gordon Chair in Family Medicine at McMaster University, helped to assess the current and past influences that shape the changing framework of medicine and to understand how Choosing Wisely Canada can be considered part of the current era of medicine.
According to her analysis, the first era of medicine was characterized primarily by the autonomy of medicine, a binary relationship between the physician and the patient, and the introduction of a social contract between the population and the medical community.
A second era followed based on accountability and market theory that focused on volume, the standardization of care and the introduction of care pathways or intervention protocols.
We are now entering an era of quality. People no longer die from general infections such as the Spanish flu, but rather from cancers and cardiovascular diseases. This results in drugs for many older people, to the point that today, the main cause of death among elderly patients is medication. So it is necessary to adjust medical practice to adapt to this new era.
Physicians must focus on professionalism and trust. Hence the importance of encouraging the Choosing Wisely Canada community to continue to improve patient care and the health care system.