Think back on your most recent visit to the doctor’s office. Chances are you were prescribed some medication, diagnostic test, or medical procedure, but did you feel like it was necessary for addressing your health concerns?
According to a study done by the Canadian Institute for Health Information, 1 in 4 Canadians have received medical care that they did not feel was necessary for their health. This amounts to 1 million unnecessary medical care treatments experienced by Canadians each year. That’s a lot!
What is unnecessary medical care? It is any test, treatment, or procedure that does not improve a patient’s health, and can potentially cause harm. For example, antibiotic overuse can cause allergies, rashes, diarrhea, and antibiotic resistance. Medical imaging overuse can cause radiation exposure that increases lifetime risk of cancer. It can also be a huge waste of resources, time, and money — for the hospital, physicians, and patients.
Choosing Wisely Canada (CWC) is a national, clinician-driven initiative that aims to address this problem. They identify tests, treatments, and procedures that offer no value to patients, and encourage discussions between physicians and patients about appropriate, evidence-based care to avoid unnecessary harms and costs. A big part of their mission is fighting back against routine testing and recommending having real conversations to individualize care to the needs of the patient.
I had the chance to speak with Dr. Lucas Chartier about CWC. He is an emergency medicine physician and Deputy Medical Director at the UHN Emergency Department, and most recently, the UHN Medical Director of Quality and Safety.
With an interest in quality improvement and patient safety, he worked with the Canadian Association of Emergency Physicians to create a list of ten tests, procedures, and treatments common in emergency medicine but potentially harmful to patients.
I mentioned that when I was first introduced to CWC, I was a bit surprised: how can there be such a thing as too many tests? I mean, isn’t it better to catch something early — to be safe than sorry? Dr. Chartier says this is not necessarily true, and in fact, this way of thinking stems from our cultural belief that more is better.We tend to believe that we need more consumer goods, more free time, more relationships, more land, more everything. It is a belief that fuels environmental destruction through consumerism, habitat loss, “infinite” economic growth: all in the quest of more.
Our relationship with medical care is no different.
But more is not always better! Dr. Chartier tells me a story about a patient with a viral infection who insisted on being prescribed antibiotics because they were used to taking medication when sick. Although antibiotics cannot treat viral infections, the doctor prescribed the medication to satisfy the patient. After all, antibiotics are not normally too risky. But unfortunately, the patient had an allergic reaction that caused issues in their colon and they ended up needing a pretty serious surgery.
All of this could have been avoided if the doctor and patient had a good conversation! Both parties were not willing to discuss what was best for the patient, and the unnecessary care led to avoidable surgery.
When doctors ask questions such as “are you on any medications” and “what is your medical history”, they are trying to gauge the risks and benefits of medical care. These questions come from countless studies investigating this very issue! And although antibiotics may seem low risk in many cases, they can also have very serious consequences. Even if the patient did not have the allergy, the antibiotics still should not have been unnecessarily prescribed, since antibiotic resistance is a huge issue. Antibiotics are so overused that many microbes have evolved the ability to defeat the drugs meant to kill them. This can make certain antibiotics ineffective and cause an imbalance in the relationships between microbes in the ecosystem. If you would like to learn more about antibiotic overuse and resistance, check out this Talkin’ Trash blog post on the topic!
Unfortunately, risks and benefits tend to be assessed in terms of general population instead of the individual patient. In one study, it was found that the top indicator for whether a patient was told to get medical imaging was not the patient, their stories and concerns, but rather the hospital they were in! But as a physician, Dr. Chartier tells me, even if a low-risk treatment only has 1% of users experiencing side-effects, you can never know if your patient is that one percent. That is why it is important to have conversations and personalize care, so that “more is better” changes into “this is what is best for me”.
Dr. Chartier emphasizes that waste is not only bad in itself, but because it leads to more waste. When one patient’s time is wasted by getting testing that they did not need, it means that someone who truly needed the testing now has to wait longer. A bottleneck builds up, contributing to the emergency department’s long wait times. Imagine having to wait less for medical care if only physicians and patients had these important conversations!
He says one of the biggest challenges in confronting unnecessary care is that both physicians and patients enter the encounter with certain expectations. Since “more is better” is the default cultural belief, it is assumed that both parties also believe it. What often happens is that the patient insists on receiving the treatment they believe they need without having a full understanding (nearly half of patients expect a drug prescription when they visit a doctor’s office) or that the physician provides treatment they are familiar with, out of habit and/or to avoid potential malpractice lawsuits.
So how can you avoid unnecessary care? Both CWC and Dr. Chartier agree that the key is open dialogue. We must have more conversation with our healthcare providers. This can be difficult if you don’t know what to say, but CWC has listed four questions you can ask to get started:
- Do I really need this test, treatment or procedure?
- What are the downsides?
- Are there simpler, safer options?
- What happens if I do nothing?
These questions should be enough to get the ball rolling, and remember that you should always feel comfortable with your healthcare provider. By having these conversations, everyone can ensure that medical care is administered according to actual patient needs and we can move past the “more is better” belief in the healthcare.
Want to learn more? Check out the Choosing Wisely Canada website and this video called “Do More Screening Tests Lead to Better Health?” from their YouTube channel!