Physicians’ professional responsibility, and calling, is to provide the highest quality of care for patients. We base our care on scientific evidence to guide our recommendations to patients. Choosing Wisely Canada is a campaign to help physicians and patients engage in a conversation about tests, treatments and procedures that are not needed and to support them in making smart and effective choices to ensure high quality care. Choosing Wisely Canada is not about cost cutting or rationing.
Through Choosing Wisely Canada, national physician medical specialty societies and the Canadian Medical Association are developing lists of five tests and treatments in their specialty that may be unnecessary or even cause harm to patients. Each specialty’s list includes five items that begin with the words “Don’t” or “Avoid”, like “Don’t order imaging studies (MRI or X-ray) for low back pain unless red flags are present.” The lists are designed to encourage physicians and patients to think about whether the test is really needed or whether it might not add any value for the particular patient. If the test or treatment is the right thing for the patient, it should be ordered. If not, it shouldn’t be.
Why is avoiding unnecessary tests and treatment good for patients? Scientific studies show that some tests do not contribute positively to care and can cause harm. For example, antibiotics for a viral illness don’t work to make patients better and they can lead to allergic reactions and antibiotic resistance. For example, a CT scan can find small, inconsequential abnormalities that lead to more testing (including biopsies or procedures) that are uncomfortable, can have complications and weren’t needed in the first place. A CT scan also exposes a patient to X-ray radiation unnecessarily (radiation from a CT scan of the head is equivalent to 25-300 chest X-rays). Good medical care is based on scientific information, and physicians and patients talking together about what is right for their situation.
So why would there be unnecessary tests undertaken at all? There are several reasons. Sometimes patients request tests thinking they are needed – in fact, advertising often encourages patients to get new types of “advanced imaging” or certain pharmaceutical treatments even when they are not scientifically indicated. Patients may think that if they come home from a physician visit without a prescription or test, they didn’t get needed care. Physicians often want to do tests to rule out rare diseases even when the probability may be very low. They may worry that a patient might sue them if they miss this rare diagnosis. Physicians may have learned to order certain tests but the scientific evidence evolves over time. Neither physicians nor patients like uncertainty and may hope tests will resolve it – even when that is not possible. Over all, we have a sense in society and in medicine that “more is better” even when that is not necessarily not true.
Choosing Wisely Canada is a great example of physicians stepping forward to do the right thing and work with their patients and to start a much needed dialogue with patients and the public. This is not a rationing exercise. It is about good medical care and patients making the best informed decisions with their physicians.
Wendy Levinson is chair of Choosing Wisely Canada and chair of the Department of Medicine at the University of Toronto