Learning from the neighbours

There is an evil tendency underlying all our technology—the tendency to do what is reasonable even when it isn’t any good.

Robert Pirsig, Zen and the Art of Motorcycle Maintenance

Earlier this summer a middle-aged man with a history of degenerative disk disease in his neck came to see me after an episode of acute low back pain following an active weekend of yard work at his cottage. He had no red-flag symptoms, but he had managed to convince the resident who had seen him 10 days earlier to send him for lumbar x-ray scans and some “routine” blood tests. Not surprisingly, his blood test results were normal and his films showed “mild to moderate degenerative disk disease.”

I am still waiting for the bill from the Ontario Ministry of Health for the unnecessary x-ray scan. That’s because in May 2012, the Ministry announced changes to billing for x-ray films, computed tomography (CT), and magnetic resonance imaging (MRI) for evaluation of low back pain.¹ The hospital where I refer patients for CT scans and MRI has adopted guidelines published by the American College of Physicians in 2011, and any physician request for one of these tests will be declined except for patients with “severe or progressive neurological deficits or signs or symptoms that suggest a serious or specific underlying condition.”² This, apparently, will be determined by the radiologist.

For plain x-ray scans of the low back, changes to the Ontario Health Insurance Plan schedule of benefits stipulate that x-ray scans for the lumbar spine will be covered only if there is a “suspected or known pathology,”¹ and that the physician ordering the test might be responsible for footing the bill if the test is found “not to be medically necessary.”¹ How the appropriateness of the test will be determined (and by whom) is not clear. Not surprisingly, Ontario physicians have been upset by these changes, not least because neither FPs, who order most of the tests, nor radiologists, who perform them, were consulted in the process.

There is no doubt that overuse of such tests has contributed to growing wait times and health care costs in Canada. But perhaps we can learn something about reducing unnecessary testing (and other waste) from our neighbours to the south. Recognizing that US health care costs were escalating in no small part because of the role physicians play, Howard Brody offered an ethical challenge to his colleagues—that they recognize their responsibility to be good stewards of health care resources in the best interest of their patients.³ Further, he challenged each specialty to strike “blue ribbon” panels to develop top 5 lists: The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered .... [T]he Top Five list would be a prescription for how ... the most money could be saved most quickly without depriving any patient of meaningful medical benefit.³

In response to Dr Brody’s challenge, the National Physicians Alliance, a group of more than 22 000 US physicians across different specialties who share a commitment to delivering affordable, high-quality health care to all Americans, began a project called Promoting Good Stewardship in Clinical Practice.⁴ Out of the project emerged top 5 lists in the primary care disciplines of general internal medicine, pediatrics, and family medicine.

What are the top 5 in family medicine? Not surprisingly the list includes x-ray scans for low back pain, antibiotics for acute sinusitis, bone mineral density tests for younger women and men, Papanicolaou tests in women younger than 21, and so-called routine laboratory tests.

However, to really improve clinical practice, much more than a top 5 list is needed, and the application of a “less is more” approach to low back pain is instructive.^5,6

Our system faces the same pressures as the US one, and we can and should learn from the Good Stewardship project. Rather than governments foisting “draconian” cost-reduction measures on us, can family medicine take the lead in promoting good stewardship of resources and better outcomes for patients? What would that look like?

Medical organizations committed to affordable, high-quality health care for all, like the College of Family Physicians of Canada, Canadian Doctors for Medicare, and others, could take the lead. Using a broad evidence-based, consensus-building approach, in partnership with the public and governments, Canada’s FPs could be leaders in promoting good stewardship of our health care resources.

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