Some amazing colleagues of mine in British Columbia have created a ‘Sustainable Primary Care Toolkit’ - Check it out at CASCADES.

“This resource highlights ways practitioners can integrate sustainability into their clinical work in primary care settings.

It is designed around four principles of environmentally sustainable healthcare: Reducing unnecessary care, empowering patients, shifting our focus towards health promotion and prevention, and choosing lower impact alternatives. It offers examples, practice tips and links to existing resources to educate, inspire and remove barriers to change, organized around the four principles.

The toolkit was authored by Ilona Hale, MD, with contributions from Jill Norris, MD on the topic of slow medicine and Lisa Larkin, BScN on quality improvement. A working group on Planetary Health in Primary Care was engaged to determine content inclusion, design, and usability. A multi-disciplinary review was conducted in two rounds by healthcare professionals from across Canada along with input from patient partners.

It is proudly supported by the East Kootenay Division of Family Practice and CASCADES.”

UBC CPD Presents:

The Therapeutics Initiative: Bringing Best Evidence to Clinicians 2021 Virtual Event

REGISTRATION OPEN!

Keynote Speaker: Julia Belluz, host of “Show Me the Evidence”, a Canadian journalist and senior health correspondent for Vox, examines the science behind major headlines in health and medicine. Julia has covered topics including the anti-vaccine movement, shed light on major American health problems, and debunked popular pseudoscience media figures. See more of her work at: https://www.vox.com/authors/julia-belluz. She’ll present "Lessons from the trenches of evidence-based health journalism (How clinicians deal with patients that read medical journalism.)"

The course also features practical, evidence-based prescribing advice from TI Faculty and guests:

• Dr. Jamie Falk “A Deep Dive into SGLT2 inhibitors: What comes up to the surface for individual patients with diabetes?"
  

• Dr. Aaron Tejani "Common Prescribing Cascades & Is there a dose response for efficacy and harm (Assessing the evidence for commonly prescribed medicines.)"
  

• Dr. Josh Levin "Exercise prescriptions: evidence and clinical applications"
  

• Dr. Tom Perry "How well do you know the drugs you prescribe?” (Listening and observing thoughtfully can protect your patients from pointless adverse effects.)
  

Target audience: family physicians, nurse practitioners, nurses, pharmacists, allied health professionals, specialists, residents, and students; patients, caregivers, policy-makers are also welcome

“Fabulous event-timely topics, dynamic presentations, good question periods, agenda kept flowing on time.”

Details and registration at: https://ubccpd.ca/learn/learning-activities/course?eventtemplate=143

Accredited: 3.75 Mainpro+/MOC Section 1 credits

Costs ($CDN + GST): Delegate $125.00, Resident $55.00, Student $30.00

• brought to you by like-minded people who understand overdiagnosis, overtreatment, and who balance this with their clinical roles

• definitely not boring (humour and controversy!)

• free of industry sponsorship/conflicts of interest

• giving you the “highlights” from a rigorous critical appraisal of the evidence

Then, look no further!

Bupropion? Tramadol?! Lifelong prescriptions to reduce cardiovascular risk? Oseltamivir for prophylaxis?

A loose theme this year is highlighting ‘drugs we’ve continued to use but don’t really understand,’ with some fascinating video illustrations of adverse drug events (ADEs) to keep you on your toes.

Join us for this year’s virtual Bringing Best Evidence to Clinicians from the comfort of your office or home.

Therapeutics Initiative faculty and internationally renowned guest, Dr. John Mandrola, will review best evidence for therapeutic issues important to primary care and specialty medicine.

WHEN: Saturday, October 17th 2020 8:30 AM – 12:30 PM Pacific Daylight Time PDT [UTC -7: convert to your local time]

TARGET AUDIENCE: Family physicians, specialists, pharmacists, nurses, nurse practitioners, allied health professionals, residents & students

COURSE FORMAT: Half-day of plenary talks highlighted by interactive Q&A time

ACCREDITATION: 3.75 Mainpro+ / 3.75 MOC Section 1

REGISTER: https://events.eply.com/bestevidence20 (student and resident rates available; early bird discount before Sept 15)

AGENDA:

8:30      Welcome and Introductions
8:45      Keynote: Legacy prescriptions for cardiovascular risk reduction (ASA, BB, ACEI, statins): what we know (and don't know) about lifelong 
             therapy | Dr. John Mandrola
9:50      Informed questions and careful observation will increase your sensitivity to adverse drug effects and help protect your patients | Dr. Tom Perry
10:15    Stretch Break 
10:30    We need to talk about tramadol | Dr. Jessica Otte
11:00    Bupropion: the basis for its approval | Dr. Cait O'Sullivan
11:30    A safety net with several holes: Oseltamivir for influenza prophylaxis| Dr. Aaron Tejani
12:00    Summarize Key Messages from the program & Closing Remarks | Dr. Aaron Tejani
12:30    Conference Ends 

I have long followed the work of Dr Victor Montori who co-developed the concept of Minimally Disruptive Medicine, which seeks to advance patient goals for health care and life, using effective care programs designed to respect the capacity of patients and caregivers and minimize the burden of treatment on their lives.

It’s very exciting that the Therapeutics Initiative (TI), an organization that I work with, will be hosting him on September 23rd for a talk on his perspective on Careful and Kind Diabetes Care.

Anyone (around the world), especially patients, are invited to join:

REGISTRATION DETAILS: This is a pay-what-you-can event, offering a sliding scale from $0 – $20.
https://events.eply.com/23SeptCarefulKindDiabetesCareAwebinarwithDrVictorMontori3359362

PRESENTER: Dr. Victor Montori, MD is a Professor of Medicine at Mayo Clinic. An endocrinologist and health services researcher, Dr. Montori is the author of more than 650 peer-reviewed publications and is among the top 1% of researchers with most cited papers in clinical medicine and in social science worldwide in the last decade. He serves in the Editorial Advisory Board of the BMJ, the board of AcademyHealth, and as Director of Late Stage Translational Research at the Mayo Center for Clinical and Translational Science. He is a recognized expert in evidence-based medicine and shared decision making, and is co-developer of the concept of minimally disruptive medicine. He works in Rochester, Minnesota, at Mayo Clinic’s KER Unit, to advance person-centered care for patients with diabetes and other chronic conditions. He is the author of the book Why We Revolt – a Patient Revolution for Careful and Kind Care.

CME CREDITS: MainPro+/MOC Section 1 credits: 1.0. You must register, attend the webinar and complete the evaluation in order to receive your certificate.

The Lown Institute is a non-partisan American group that strives to create a health system that rejects low-value care, incentivizes healing over profits, promotes health equity, and honors the value of the clinician-patient relationship.

They have brought together like-thinkers to create the Right Care Alliance, host a conference on the theme of over treatment, contributed to the landmark Lancet 2017 series on overdiagnosis/overtreatment, and have now worked with partners to develop a National Action Plan on Eliminating Medication Overload.

I work with one of the endorsing organizations, the Therapeutics Initiative, a group at the University of British Columbia that offers non-conflicted critical appraisal of evidence and knowledge translation. Much of our work focusses on polypharmacy, deprescribing, and finding ways to teach and empower clinicians to do this work (like feeding-back prescribing data in individual Prescriber Portraits).

Given the alignment in goals, I’m excited to see this Action Plan from the Lown Institute come to fruition; it is aimed at policymakers, health care institutions, clinicians, and patients and provides some tangible ways that we can reduce harm from polypharmacy.

You can DOWNLOAD the plan here [PDF] or read a bit more on the website.

*Spoiler alert* there are 5 main categories to consider:

1. Implement prescription checkups

2. Raise awareness about medication overload

3. Improve information at the point of care

4. Educate and train health professionals to reduce medication overload

5. Reduce industry influence

Which do you think is the most important? What are you focussed on?

I am proud to work with an organization (The Therapeutics Initiative) which does rigorous, unconflicted review of the medical evidence. Many (but not all ) of our conclusions are essentially that the drugs don’t work as well as we wish they did. And for coming to these conclusions, we have been called nihilists.

Like anyone, I want the medications to work, and work well. Yet, I understand that they often do not, and that we need to stop pretending that they might kinda sorta a little, when the evidence says that they (sadly) really don’t make a meaningful different for outcomes that matter to patients. This can be hard to reconcile in clinical practice where clinicians and patients alike get stuck on the hope of success in the face of illness and adversity.

The authors explain there terminology further:

Our choice of the term medical conservative does not imply a political philosophy, although William Buckley Jr.'s definition of conservatism aligns well with our approach to patient care:

“A conservative is someone who stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it.1

Here is what we believe:

Medical conservatives are not nihilists. We appreciate progress and laud scientific gains that have transformed once deadly diseases, such as AIDS and many forms of cancer, into manageable chronic conditions. And in public health, we recognize that reducing exposure to tobacco smoke and removal of trans-fats from the food supply have contributed to the secular decline in cardiac event rates.2 Indeed, medical science has made this era a great time to live.

The medical conservative, however, recognizes that many developments promoted as medical advances offer, at best, marginal benefits. We do not ignore value. . . . The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased. 

In the article, they show this graph, comparing the magnitude of benefit for a patient to the cost of the care, with some examples:

The area on the left is where we want to be. The “A” items make a really really big differnce for people’s well being. Not surprisingly, a lot of the modifiable social determinants of health live in “A” territory. The trouble is the “C” territory, the things that we do that make basically no impact for patients but that cost an extraordinary amount in terms of harms, burden, and financial measures for patients and society.

My colleague Juan Gérvas said it well when he wrote our ‘preventing overdiagnosis’ mailing list: “the end of the curve is not flat, but going down... [at that point, the] harms outweigh benefits.; on the end of the flat part of the curve, additional spending, whether it be on a new drug, device or diagnostic test, confers more harms than benefits to individual patients or society".

Understanding the risks and benefits of all options is critical for effective decision-making. Those who are comfortable with uncertainty and who understand the magnitude of risks tend to excel with decision-making in health, finance, and other high-stakes fields.  By taking the time to consider a problem and engage in self-reflection, more sound decisions can be taken - but a foundation that includes statistical literacy is also required.

Many of my peers in the overdiagnosis community are professionally skeptical. These patients, clinicians, and researchers tend to ask questions like: "is that really what the data show?" "how do we know this?" "through what lens was this interpreted, are there any biases?" It is because of this type of reflection that they can distance themselves from the evidence and view it critically. It is not surprising, given our interests, that members of our community score highly on the Berlin Numeracy Test.

Curious about your performance? Test your risk literacy now.

Read the original BBC Article:  How well do you think about risk and uncertainty? for more.

While historically health care providers and administrators have been preoccupied with people underestimating risk, there are profound implications of low statistical numeracy and risk literacy for overtesting/treatment and diagnosis.

Should we enhance risk evaluation and statistical skills education in high schools? What differences would we see in our society if the majority of people had an increased capacity to question their own reasoning and judgements?

Dr Roland Grad is back again with another persuasive publication regarding POEMs that align with principles of the Choosing Wisely campaign.

I find that infoPOEMs are a quick way to learn about new developments in practice and many of the topics align well with my interest in avoiding unnecessary and harmful care. Drs Grad and Bell have reviewed last year's POEMs with that lens, and their paper offers a great source of input for Choosing Wisely recommendations, as well as a launching point for changing your own practice.

Dr Grad will be presenting the poster at the Preventing Overdiagnosis 2018 conference in Copenhagen.

You can read the full publication here, in AFP.

Previous contribution from Dr Grad and colleagues to this blog can be found here:

• POEMs help identify clinical practices for the Choosing Wisely Campaign
• Choosing diagnostic tests wisely: Doing the little things well  (focus on TSH measurements, screening mammography, and mid-stream urine collection.)
• Choosing surgery wisely: the importance of evidence-based practice
• Also, please see his academic background and extensive list of publications at McGill. https://www.mcgill.ca/familymed/roland-grad

I was also re-invigorated by the energy of the Students and Trainees Advocating for Resource Stewardship (STARS), and reassured by the Canadian Medical Protective Association's endorsement of the Choosing Wisely campaign.

Dr Dee Mangin delivered a compelling, philosophical keynote to close the conference; she explored the issues driving medicalization and polypharmacy, and offered some hope for taking action against these. There were many reality checks for the audience, and recent research on physician behaviours, publication biases, a society obsessed with risk surprised many. Some of this was very familiar to me from discussions and presentations within the Preventing Overdiagnosis community, but Dr Mangin has a way of explaining things in such a way that their profound nature hits you like a tonne of bricks. (This is a good thing!)

It was clear at the conference that things have to change. But what is that vision, exactly?

One idea that was new to me was that of the "3rd Era of Heath Care," a concept developed by Dr Don Berwick, of the Institute for Healthcare Improvement (IHI). Dr Mangin touched on it and I think it's an idea worth sharing:

Maria Llargués Pou, a soon-to-be Family Physician in Barcelona, recently shared with me her Bachelor's Thesis. 

Her work - "Primum non nocere" Preventing Overdiagnosis, the Quaternary Prevention provides a concise introduction to the efforts around the world to prevent overuse of tests, treatments, and disease-labels, as well as the reasons we must address this growing issue.

Llargués Pou has beautifully laid out an evolution of ideas, from Ivan Illich's idea of Iatrogenesis, to Jamoulle's attempts to thwart iatrogenic harm with a public health model of Quaternary Prevention, and now, contemporary efforts to tackle overdiagnosis, like the Choosing Wisely Campaign and Preventing Overdiagnosis conference. Her paper serves as a great "backgrounder" for those who wish to learn more about the broad themes and history of this movement.

You can view the full text HERE.

Jenniskens, a PhD student at Utrecht University, et al looked at almost 5000 studies and included 1581 for review. Unsurprisingly, the majority of papers pertained to the field of oncology, perhaps because wide-spread screening programs and attempts for early diagnosis are much more common for cancer than for chronic disease and other conditions. Though they did not publish the information, they also took a moment to determine from where in the world the papers were being written.

For years, I have been fascinated with the geographically diverse response to the problem of overdiagnosis and the idea that overdiagnosis can happen in resource-rich and -poor countries alike. I worked with Alan Cassels to facilitate a group discussion at the Preventing Overdiagnosis conference in Barcelona in 2016. We identified movements that attempt to combat overuse of tests, treatments, and procedures around the world (presentation slides are available here) and discussed what factors in each region might be playing a role.

Seeing that presentation and recognizing my interest, Mr Jenniskens has since kindly provided me with a breakdown of the country of origin of the authors for the papers analyzed in his group's review. While most of the papers were tied to the United States, first authors from 65 different countries were among the 1581 papers.

Please click through to interactive map to view the % proportion of authors of the 1581 assessed papers, originating from each country. From Albania to Zimbabwe, it is clear that overdiagnosis is a global concern, and is being researched everywhere.

Read more about the papers considered in the scoping review.

Over the past year, I had the opportunity to contribute to the formation of several toolkits on the topic of "Resource Stewardship." These toolkits were created by the Royal College of Physicians and Surgeons of Canada (RCPSC) in partnership with Choosing Wisely Canada and the College of Family Physicians of Canada (CFPC).

The aim was to create modules that educators could use in order to encourage residents to be mindful of overdiagnosis, overtesting, and overtreating as they prepare for practice. By empowering them to have conversations with patients about unnecessary medical interventions and to undertake Quality Improvement projects in this area, preceptors can ensure that physician trainees satisfy the societal duty (as well as a residency education CanMEDS requirement) to be good stewards.

There are THREE toolkits, each containing a powerpoint and preceptor guide:

1. Foundations - basic information, vocabulary to facilitate residents becoming mindful of considering the (broad) harms and benefits of any test, treatment, or procedure.
2. Projects - information and guidance on how to undertake a scholarly (eg. research or QI) project in this area
3. Communication - scenarios, role play, and other resources to help residents communicate with patients and families who may request an unnecessary test, treatment, or procedure

You can find more education resources on the teaching page.

In just over 8 minutes, she beautifully articulates the issue and a vision of how we can address it.

Dr Navjoyt Ladher of BMJ talk medicine kindly invited a few colleagues and me to participate in an informal discussion at the Preventing Overdiagnosis 2017 conference in Quebec, Canada.

As working clinicians, we explored moments in our careers that got us interested in tackling overdiagnosis, scratched our heads thinking a little bit about why we (and not all of our colleagues) are taking this on, and reflected on take away messages from the conference.

Have a listen, and go to the original site if you wish to join the discussion.

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Medicine is undergoing a huge transformation, shifting away from the historic model of paternalistic, top-down, doctor-driven health care. We started towards patient-driven, consumer medicine, and thankfully are starting to settle at a beautiful middle-ground, which is patient-centred care, using interdisciplinary clinician expertise, and a process of shared decision making around a patient's needs and priorities.

That is a lot of words, when really what it boils down to is this: shifting the emphasis towards caring for people rather than 'doing medicine.'

Or in even simpler terms, we should be asking "What matters to you?" and shaping the care we give to help people find the best fit for their goals. 

This is a new initiative in British Columbia, organized by the BC Patient Safety Quality Council (BCPSQC), to promote meaningful conversations around health care between patients and providers. "What Matters to You?" Day is based on a now global campaign that started in Norway in 2014.

We already incorporate this into our work in the Palliative Care and 'ED2HOME' services at my hospital, but I am keen to help spread the word for this very important idea so that all patients have a chance to answer the question.

From the BCPSQC:

Why does it matter?
Because we believe great care begins with a question. Providing patient-centred care is important because it results in better outcomes for patients and greater satisfaction with care. “What Matters to You?” Day supports this by putting the patient voice at the centre of care, by focusing on what matters to them.

When a health care provider starts a conversation by asking what really matters to the person they are caring for, it helps them to build trust, develop empathy, and understand their patients. Ultimately, it improves the quality of care they provide.

There are lots of ways you can support "What Matters to You?" Day! 

• Join us & declare your intention to have a conversation about what matters, whether you're a care provider, patient, family member, or health care provider
• Download our Getting Started Kit & learn more about the campaign
• Order free resources to promote "What Matters to You?" Day. We've got posters, pocket cards, stickers, and more resources designed for patients and providers. We'll mail them anywhere in BC! 
• Spread the word online using our simple, prepared messages and digital resources!
• Get ready for conversations about what matters with our skill-building tools
• Watch and share the campaign video, above

Celebrate The Virtual Launch!
We'll be sharing messages about "What Matters to You?" Day across digital channels, so join the conversation on Twitter, Instagram, or Facebook by using the hashtag #WMTY17! You can even add a #WMTY17 Twibbon to your profile photo to spread the word with every message you share!

Learn more: What Matters to You Day

When I speak to peers and clinicians, one of the most frequent bits of feedback I receive is "Great! I'm on board with delivering more appropriate care, Choosing Wisely, making sure my patients make shared decisions and avoid unnecessary tests and treatments. But... I don't really know how to 'do' it. Where do I start? How to I talk to patients? Where do I go to practice?"

So, it is with extreme pleasure that I announce the expansion of the Practicing Wisely: Reducing Unnecessary Testing and Treatment Course. Originally "Don't just do something, Stand there!," this highly-regarded hands-on learning experience was started by the Ontario College of Family Physicians and is spearheaded by Dr Jennifer Young.

It is now a suite of continuing professional development opportunities for primary care providers, available in a modular format across the country. In the course: 

Participants will identify opportunities to "practise wisely", with a focus on reducing over-prescribing, over-imaging, over-screening and over-monitoring using the latest evidence and tools from diverse sources. This workshop aligns closely with the Choosing Wisely Canada (CWC) campaign to implement good healthcare stewardship and avoid over-medicalization.

The program centres on case studies and incorporates individual reflection and group work. It helps participants to build communication skills to guide their patients through the shift from seeking sickness to enhancing health.

After active engagement in this program, participants will be better able to:

• Identify opportunities to reduce “too much medicine”
• Access and assess reliable, renewing online resources
• Integrate relevant evidence into individual patient care
• Communicate and build consensus with patients to reduce over-medicalization

Upcoming Workshops are taking place as follows:

May 24/17 - Montreal
May 29/17 - Ottawa
June 3/17 - Newfoundland
Nov 22/17 - Toronto

Find out more about the Practising Wisely program by viewing the main website or reading through this Q&A with Course Director, Dr. Jennifer Young.

In partnership with the Saskatchewan Medical Association, they have now launched Choosing Wisely Saskatchewan and are working engaging patients, clinicians, and learners to implement a province-wide strategy to tackle overuse. To start, they are focussing on pre-operative testing and imaging of lower back pain, and some of the health regions are taking on their own projects.

The Cypress Health Region has demonstrated their commitment to Choose Wisely:

Here's hoping many people will see their example and make the same pledge to choose wisely - because more is not always better in healthcare.

The Right Care Alliance is sponsored by the Robert Wood Johnson Foundation, something it has in common with Taking Action on Overuse.  While the former is more directed at patients, clinicians, and policy-makers, Taking Action on Overuse is a group that seems devoted to supporting health organizations and institutions. Organizations interested in creating changes to provide fewer unnecessary or harmful tests, treatments, and procedures, can employ the tools Taking Action has created. 

In their words, "Taking Action on Overuse is an evolving framework for health care organizations to engage their care teams in reducing low-value, unnecessary care and make those efforts last. It identifies evidence-based strategies for obtaining buy-in, motivating behavior changes, and providing the necessary support and infrastructure for health care providers to engage and lead their peers in making the changes that improve the value of health care."

Their Assessment can help you figure out whether your institution is ready with best practices, and gently guide you there. Likewise, their Framework can help you create the right conditions for change in a climate where many still believe "more is always better."

Check out their website here to learn more.

(Original post)

A National Discussion: Unnecessary Care in Canada

The Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada (CWC) invite you to join us for a discussion on the extent of unnecessary care in Canada.

This webinar will introduce a new CIHI/CWC report, Unnecessary Care in Canada, and facilitate a conversation about the magnitude of and variation in unnecessary care across several areas covered by CWC’s recommendations.

The event will include

• A moderated panel discussion with:
  • David O’Toole, President and CEO, CIHI;
  • Dr. Wendy Levinson, Chair and Co-Founder, CWC; and
  • Dr. Laurent Marcoux, President-Elect, Canadian Medical Association
• Speakers from the Canadian Partnership Against Cancer, North York General Hospital and other organizations, who will share their success stories about addressing unnecessary care
• Q & A session

Date: April 6, 2017
Time: 9 to 10:30 a.m. ET

Please note that this webinar will be conducted in English only and will use Eastern Time. To accommodate multiple time zones, a recorded copy of the webinar will be made available. When you register, please specify if you would like the recorded version.

Registration: To participate, you must have access to the internet, as well as speakers/headphones. The webinar will be accessible on iOS and Android devices (both mobile phones and tablets).

To register for the webinar, please email Alison Clement at aclement@cihi.ca