Winter 2015 (Volume 25, Number 4)
Choosing Unwisely
By Philip A. Baer, MDCM, FRCPC, FACR
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“You can only fall in love six times in your life. Choose wisely.”
–
Douglas Coupland Changing behaviour is difficult. One of my favourite examples relates to Vitamin C and scurvy. It took 42 years from the time that scurvy was identified as being preventable by ensuring an adequate intake of citrus fruit until the British navy mandated that each sailor receive a ration of fresh oranges and lemons daily.1
Adult education talks about achieving a zone of mastery, where patterns are recognized and actions taken semi-automatically without great mental effort. The concepts of muscle memory and “ten thousand repetitions” or “ten thousand hours” in sport and the performing arts have a similar background.2 I appreciate this daily, as my 20 km commute to and from work happens without my consciously recalling each traffic light or turn en route. The drive seems so much longer in bad weather, when more concentration is required.
In the office, we benefit as well. For simple conditions, we can almost predict the patient’s answers to our questions before they are uttered. Physical examination findings in these situations are usually not surprising, and are anticipated based on the history. One develops a set of mental speeches that can be unspooled and recited to cover the basics of the diagnosis and treatment plan.
Problems arise when new medical information becomes available, requiring a change in what we do. It is hard to overcome learned habits and inertia unless the information is clear-cut and compelling; even in those cases, knowledge translation remains a challenge. In other situations, physicians may never have learned the correct approach in the first place—a particular challenge in rheumatology, which I believe does not receive an adequate allotment of instruction time in undergraduate and post-graduate medical training. This applies particularly to physicians who will staff the front lines of primary care, where musculoskeletal conditions are so prevalent.
The results unfurl in my office daily. Most of my referrals come from family physicians and general practitioners, who seem to have been taught that a rheumatology referral requires ordering a battery of tests I would never ask for, such as rheumatoid factor (RF), antinuclear
antibodies (ANA), anti-double stranded DNA (dsDNA) and complement studies in routine cases of knee osteoarthritis (OA) or low back pain. This has been repeatedly documented in the clinical literature.3,4 Similarly, the desire to order knee and spine MRIs seemingly cannot be overcome easily, even when plain knee
X-rays demonstrate abnormalities, and when there is no spinal surgery in view.
What will it take to really make a difference? Pressure on healthcare budgets will make an impact eventually. We are already experiencing freezes and cuts to physician fees in Ontario, with offers to restore funding if physicians can propose system-savings initiatives which would reduce spending on unnecessary lab testing and imaging. I have
great hopes for Choosing Wisely Canada, spearheaded nationally by Dr. Wendy Levinson, and for the CRA’s Choosing Wisely initiative, led by Dr. Shirley Chow.
The matrials and evidence are compelling. Knowledge translation and dissemination will be
critical. Perhaps increasing patient knowledge will lead them to question and educate the medical practitioners they encounter. Personally, I am taking every opportunity to present this material when I am given a choice of continuing medical education (CME) topics, including at journal clubs, at cruise CME conferences, and at events such as Primary Care Today.
I remain hopeful that the next generation of electronic medical records (EMRs) will integrate testing guidelines at the point-of-care, as well as dashboards to optimize care as it happens. Perhaps a pop-up will appear on a general practitioner’s screen when they order a “rheumatology panel” of labs on a patient with simple hip or knee OA. Maybe it will stop the ordering of anti-dsDNA and extractable nuclear antigens (ENA) panels when the ANA status has not yet been determined. One can only hope.
References
1. Glouberman S. Knowledge transfer and the complex story of scurvy. J Eval Clin Pract 2009; 15(3):553-7.
2. Ericsson KA, Krampe RTh, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993; 100(3):393-406.
3. Miller A, Mahtani KR, Waterfield MA, et al. Is rheumatoid factor useful in primary care? A retrospective cross-sectional study. Clin Rheumatol 2013; 32(7):1089-93.
4. Abeles AM, Abeles M. The clinical utility of a positive antinuclear antibody test result. Am J Med 2013; 126(4):342-8.
Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario |
