If you have a cold or cough, an antibiotic may not be the cure. If you have a minor injury from playing hockey, a CT scan of the head may not be necessary. Then why do so many doctors prescribe these, and what can be done to stop it?
On this episode of The Dose, Shanoor Seervai interviews Wendy Levinson, M.D. and Karen Born, who run the Choosing Wisely Canada campaign. Based on the philosophy, ‘more is not always better,’ Choosing Wisely is a campaign to help clinicians and patients engage in a dialogue to avoid unnecessary medical tests, treatments, and procedures.
WENDY LEVINSON: During the winter many of you may go to the doctor, seeking care for a cold or a cough. In fact, many of you may receive antibiotics for your cold or cough. But it might surprise you to know that these antibiotics don’t treat viruses, which are the cause of these common colds. It is estimated that one in every two antibiotic prescriptions written are not necessary and don’t help people get better faster. In fact, they can lead to complications and resistance, or the inability of antibiotics to be effective for infections.
SHANOOR SEERVAI: So you’re saying that about half of the people taking antibiotics are taking them when they don’t actually need them?
WENDY LEVINSON: Yes, I am, and this is not just a problem with antibiotics. We know that in many countries, including the United States and Canada, about a third, or 30 percent, of all the health care delivered may not add value for patients, and can even be harmful. This is true in screening tests, diagnostic tests, and procedures, in addition to medications, that don’t necessarily help patients, and can cause harm.
SHANOOR SEERVAI: Hi everyone, welcome to The Dose. On today’s show, we’re going to be talking about overuse of medical care — this is a growing problem across the globe, because it puts patients’ lives in danger, drives up costs, and is a drain on the precious resources of a health system. But what can we do about it?
We’re going to learn about one campaign that’s trying to solve the problem with Dr. Wendy Levinson and Karen Born. Wendy and Karen work on the Choosing Wisely Canada campaign, based at the University of Toronto and in partnership with the Canadian Medical Association. They have been working for several years on how to change the problem of too much medical care.
Wendy, Karen, thanks for joining me.
WENDY LEVINSON: Thanks for having us.
SHANOOR SEERVAI: To get started, Wendy, tell me when you first started thinking about overuse.
WENDY LEVINSON: Well, I trained quite a long time ago, and in fact, we were never taught about overuse. In training, we frequently learned patterns of practice that incorporated overuse. And it’s only recently with the beginning of Choosing Wisely, which started in the U.S., that I really started to think about how often we use things, tests or treatments, that don’t help patients and can be harmful.
SHANOOR SEERVAI: And, so doctors form these habits, but Karen, it’s not just physicians, right? Patients also expect to get treatments that may be wasteful, and even harmful?
KAREN BORN: Yes, definitely. Research shows that when patients go to the doctor with a health concern or complaint, they also have the expectation that they will receive a prescription or test. But we know that additional testing, like unnecessary imaging tests like X-rays or CTs, can expose patients to radiation.
SHANOOR SEERVAI: And when did the two of you start working on solutions? Let’s start with you, Wendy.
WENDY LEVINSON: Well, I spent much of my medical career in the United States, and more recently in Canada. In the U.S., I worked with the American Board of International Medicine (ABIM) Foundation that began the Choosing Wisely campaign in the United States in 2012.
SHANOOR SEERVAI: So Choosing Wisely is the campaign we’re going to be talking about on this show.
WENDY LEVINSON: Yes. So overuse has been a serious problem in many countries for decades, but physicians have not really been engaged in it. In fact, they were resistant because they thought these decisions were what they called, “rationing care at the bedside.” What’s happened with Choosing Wisely that’s been so successful is that it’s very grassroots, it engaged physicians and gave them a language to talk about overuse in a way that framed it as about patient safety and quality. And that’s what doctors and patients care about. I helped to bring the campaign to Canada, where we started just over five years ago, and now it has spread to many countries in the world.
SHANOOR SEERVAI: And how did you get involved, Karen?
KAREN BORN: I joined the Choosing Wisely Canada team to help take research and evidence-based information on the campaign to the people who can put it into action and practice, and also to help try to spread the word to patients and the public.
SHANOOR SEERVAI: So what’s the core mission, in one sentence, of Choosing Wisely?
WENDY LEVINSON: Choosing Wisely is a campaign designed to help clinicians and patients engage in conversations about unnecessary tests, treatments, and procedures, and help patients make good choices about what is right for their care.
SHANOOR SEERVAI: Wendy, what are some of the things you’re doing to achieve this?
WENDY LEVINSON: The campaign works with national clinician societies to prepare lists of recommendations in their specialty, for which there is excellent scientific evidence of overuse or even harm to patients. For example, the Canadian Association of Hospital Dentists recently released a recommendation that reads, “Don't use opioids to treat pain after procedures like wisdom teeth removal . . . instead use over-the-counter pain medications like Tylenol.” These are all very simple statements.
SHANOOR SEERVAI: That’s interesting — the idea here is that a simpler and milder treatment may be more effective.
WENDY LEVINSON: Exactly.
SHANOOR SEERVAI: But there must have been other efforts, before Choosing Wisely, to address this problem of overuse. Can you talk about how you fit into other campaigns or programs?
WENDY LEVINSON: Choosing Wisely definitely is part of a broader, growing understanding of patient safety and quality improvement, and there has been a lot of traction in that over the past few decades. In the patient safety movement, for example, it started by recognizing that it wasn’t individual doctors who made mistakes and caused safety problems, but there were system problems and errors that had an impact. This movement has really been focused on improving quality and identifying solutions. Choosing Wisely is situated within this because it’s about clinicians identifying overuse within their specialty, describing it, and offering solutions or ways to reduce it.
SHANOOR SEERVAI: Okay, and how has Choosing Wisely added to this movement?
WENDY LEVINSON: There’s a growing awareness that engaging patients in their care can result in improvements to outcomes, along with improving patient satisfaction. So Choosing Wisely has done two unique things — one is it’s ground-up, it engages the clinicians, and secondly, it really focuses on the conversations between patients and clinicians.
SHANOOR SEERVAI: So you mentioned that the campaign started in the U.S. and you brought it to Canada, but that it’s also spread to several other countries. How did that happen?
WENDY LEVINSON: You know, it’s really interesting, when you think about how different our countries and health care systems — it would be surprising — but many countries, now over 20, have started to develop a Choosing Wisely campaign. The campaign is simple, and grassroots, and being a doctor or a clinician of any kind and working with patients is really similar across the world. Even though our cultures are different, our health care systems are different, the way we work between a clinician and a patient, the way we make decisions, that is universal.
SHANOOR SEERVAI: What are some things that are universal to doctors across the board?
WENDY LEVINSON: Tests and treatments that can cause harm—we all see that in practice. It helps to talk with patients about what not to do and have a language that is comfortable discuss these problems, like why not use antibiotics so that patients understand there are harms.
SHANOOR SEERVAI: So you’re saying that Choosing Wisely has appeal in these vastly different contexts because countries have the freedom to adapt it to meet their needs. But are there some treatments that tend to be overused the world over?
WENDY LEVINSON: The most common example is overuse of antibiotics. It’s a worldwide problem. When patients don’t feel well, they go to their doctor seeking help with a cold, and it’s very common for people to think antibiotics are the solution. And doctors are busy, and so it takes a bit of time to have a conversation about why they might not need the medication, why there are other things that can help them feel better while the cold runs its course, and help reassure patients that the treatment might not be necessary, or even harmful. So that’s one that happens in every country.
SHANOOR SEERVAI: And how did you get doctors interested in something like this?
WENDY LEVINSON: This is quite interesting, because the campaign has really taken off, and I think it’s because it focuses on those conversations. In many circumstances, the campaign helps doctors have these conversations in a more comfortable way. It really speaks to the essence of being a clinician.
SHANOOR SEERVAI: Makes sense. You’ve spoken a lot about how you’ve engaged doctors. But Karen, tell me where patients fit in.
KAREN BORN: So Choosing Wisely campaigns have set a big and ambitious goal, not only to encourage conversations among physicians about overuse, but to change patient culture and public expectations when they go to see their doctor. A few years ago, in Canada, we launched a public campaign called “More Is Not Always Better,” designed to encourage patients to ask clinicians questions about whether that test or treatment is really necessary.
SHANOOR SEERVAI: And part of this campaign was putting posters up in doctors’ offices, right? Tell me more about that.
KAREN BORN: Absolutely. So we mailed out posters to all family doctors across Canada. These posters are eye-catching, with very few words — not the usual images you see in a doctor’s office. So, one is a hot dog absolutely smothered with too much mustard. Another poster has a washing machine overflowing with soapy suds, and finally a poster of a person trying to lift a weight that’s too heavy for them. The message is clear — it’s good to wash your cloths or lift weights and exercise, but too much soap or a too-heavy weight causes more harm than good. More is not always better.
SHANOOR SEERVAI: It sounds like you have a lot of resources to get people thinking and talking about the problem, but how do you actually get doctors to prescribe less, or patients to say, “No, I don’t actually want this test or procedure”?
KAREN BORN: There is a lot of work to be done here. For patients and the public, we dedicate a lot of time to sharing campaign information broadly — we work with national media outlets, and through social media talking to clinicians to figure out how recommendations can be shared in ways that are most relevant to the most people. I’ll give you one recent example: Amy Ma, one of our patient advisors, cowrote an op-ed with a dentist who leads Choosing Wisely for the Canadian Association of Hospital Dentists.
SHANOOR SEERVAI: What did they write about?
KAREN BORN: Well, Amy, our patient advisor, has three children, and one of her sons, who is a teenager, went to the dentist for wisdom tooth removal, and after that he was prescribed an opioid for pain. The Canadian Association of Hospital Dentists recommends against this practice. Given the current opioid epidemic, Amy thought twice when she got that prescription, and she was aware of the recommendation against this, so she questioned the dentist and received a different prescription for a nonopioid pain reliever. She really wanted to share her son’s experience and to share the experience with other parents of teenage kids. And evidence shows that prescribing opioids to teens after wisdom tooth removal can cause long-term harm and increase the risk of opioid abuse in the future.
SHANOOR SEERVAI: And how did people respond to this op-ed?
KAREN BORN: So, the op-ed was published in national and local news outlets across Canada and generated a lot of interest. What we’ve found in Canada, and what’s seen in research, is that stories can help personalize the problem of overuse and get people thinking about how overuse might apply to themselves or their loved ones. And really, changing culture and behaviors is a long-term challenge, and by sharing stories like these, we can keep chipping away at it.
SHANOOR SEERVAI: I guess when you talk about changing behavior, and how long it takes, this comes down to what students learn in medical school as well. I’ve spoken to Dr. Brian Wong about a program he’s running, that came out of Choosing Wisely Canada. And he said one issue is that in medical education, the way to show your seniors how much you know is to order all the tests, because it demonstrates that you’ve thought through all the possibilities for that patient. But, of course, this may not be helpful for the patient, or for the system at large.
WENDY LEVINSON: Yes, I really agree with that, medical students learn to leave no stone unturned. Physicians often feel uncomfortable with uncertainty or ambiguity. So let me give you an example in an emergency room: let’s say a child comes in having hit their head playing hockey. The doctor typically will examine the patient, but often the family or the doctor feel they need to do a CT scan of the head just to be sure, “just in case,” and so doctors will default to that, and if they are under pressure, quickly send the person to have a CT scan, even if the examination and the history don’t suggest it’s necessary.
SHANOOR SEERVAI: And why is this a bad thing, Wendy — to take a “just in case” precaution?
WENDY LEVINSON: That’s a good question. Tests and treatments have some downsides. If you take a CT scan, for example, if the parent knew that that might increase the child’s risk of lifetime cancer because of excess radiation, they had to wait in the emergency room a lot longer, or in the U.S., that would cost them a significant amount of money, the parent might say, “Oh, well, maybe I really don’t need that if the examination is fine.” But often when doctors are busy, or patients ask for it, the reflex instinct is to order the test.
SHANOOR SEERVAI: So, Wendy, there’s a growing trend in our health systems that more things are automated, and you’ve talked a lot about what doctors can do to implement Choosing Wisely recommendations, but what are some simple fixes we can make to the way the system works?
WENDY LEVINSON: That’s a very good point you’re raising, because often in medicine — take the hospital, for example — many things are just baked into the system. Sometimes people will come in for surgery, and there’s a box that just gets checked off automatically that says do a bunch of tests to make sure they’re ready for surgery. And that gets checked off automatically whether the person is 85 with heart disease or 20 years old with no risk factors for surgery, because it’s just part of the system. So one of the really great things is that you can use technology to ensure that some of these tests and treatments are not ordered routinely, unless they’re indicated, by changing the routine orders in the hospital, for example.
SHANOOR SEERVAI: That makes sense, and certainly sounds like something that’s easy to fix.
WENDY LEVINSON: Some of these are really systems solutions, and they don’t rely on each doctor to remember it, because once you’ve fixed it in the automated record, it just lives by itself.
SHANOOR SEERVAI: That sounds great. Looking ahead, what’s next for Choosing Wisely Canada — your next big project?
WENDY LEVINSON: Well, making the recommendations is sort of a starting point in many of these countries. But once you have the recommendations — and there are over 700 in the U.S., and over 300 in Canada — the real challenge is implementing these recommendations. Of course, these are not easy changes to make. It’s challenging to have patients understand that they don’t always need an antibiotic for a cold, or that they don’t need a head CT scan for reassurance about their child’s injury. So it’s really trying to help clinicians and patients have these conversations in practice. Also, I’d say to build systems that facilitate that conversation, to make it easier for the clinicians and patients.
SHANOOR SEERVAI: Well, I suppose it’s easier to understand a recommendation about not doing something when it’s abstract, but it’s more difficult for an individual patient. I can just imagine myself in an emergency room, after having hit my head, saying, “Yeah, we should do a CT scan just in case,” and a physician saying to me, “No, no, you don’t need that.” I may not be receptive to him.
WENDY LEVINSON: Well, that’s why I think it is really a shared decision. We encourage patients to ask four questions: do I really need this test or treatment?; what are the downsides?; are there simpler, safer options?; and what if I do nothing? And in the States, there’s a fifth question that’s frequently asked, which is: how much will it cost? So if you had heard about Choosing Wisely and learned that more is not always better, then you might ask your doctor these questions. It’s all really about having the conversation to reassure the patient that I’m doing the appropriate things to make sure your head injury is not dangerous to you, but I’m also being cautious with you, because more is not always better.
SHANOOR SEERVAI: I like that, that the doctor is being cautious with the patient. And do you see this happening more broadly, as more people become aware and want to do something about overuse?
WENDY LEVINSON: I actually feel very heartened by what’s happening, you know, in Canada, we hear often about doctors saying they are Choosing Wisely in practice. They are using it almost as a verb, because it’s become a little bit of a mind-set. We have in our surveys found that 42 percent of doctors say they are using Choosing Wisely in their daily practice, either very frequently, frequently, or occasionally. Changing a culture doesn’t happen overnight, but if you chip away at it, and you’re working on both the clinician side and the patient side, I am very optimistic that this will change with time.
SHANOOR SEERVAI: Well, let’s end on an optimistic note, then. Thank you both for joining me.
WENDY LEVINSON: Thanks for having us.
SHANOOR SEERVAI: And that’s it for today’s episode of The Dose. We’ve had some great emails from listeners so far, so if you want to tell us what you think, send us an email. Our address is [email protected]. See you next time.