The heart of being alive

Sarah de Leeuw

Dr Jessica Otte grew up on a hobby farm in northern Ontario, just outside Thunder Bay. The usual trappings of such a home surrounded her during childhood. She and her brother spent time tending chickens and chopping wood, playing hockey on a beaver pond, and exploring the great outdoors. She had no hankering to become a doctor.

“My dad was laid off when I was young. Then he retrained as a nurse, and we started talking about the human body and caregiving,” remembers Otte. “I was encouraged to be hard working and inquisitive. My family was always talking about philosophical things. The placemats on our table were maps of the world, the solar system. At dinner we were always talking and debating, looking things up in the atlas or dictionary.”

When it came time for university, a young woman from farming fringes chose cognitive systems as her major, working in laboratories and studying consciousness and the interface of people and computers.

But something was missing. “Being a well-rounded human, embracing connections with others, and marvelling at the human capacity has always been a part of me,” recalls Otte as she talks about creativity, about human spirit, about sports, and about living—living fully. “It’s what drew me to family practice. You can do anything, from delivering babies to palliative care. It takes our hands, our brains, and our hearts.”

Perhaps it was the heart, as a metaphor, as a philosophical stimulant, as an anatomic structure so intrinsically linked to life and death in the human imagination, that ultimately inspired Otte’s path. She now does hospitalist medicine and general practice in Nanaimo, BC, but also works on a much larger scale in policy and education.

Perhaps it is philosophies of the heart that fill her with a belief about listening carefully to patients when they speak about what is important to them and their quality of life, wondering if sometimes less intervention results in better care. “Sometimes we just go down this path of more, of chasing things we’ve found. But if we talk very carefully with a patient, especially an older patient, about what they care about, sometimes what they want is something very different than chasing a diagnosis.”

Otte takes umbrage at the concept of providing disease-centred rather than patient-centred care. Physicians might mistakenly believe that patients expect all the answers. Patients might think they should not challenge the expertise of physicians. A mutual comfort with uncertainty and a strong patient-provider relationship focusing on patients’ goals—where function and quality of life often out-rank longevity—is, instead, often key.

When visiting patients in a long-term care facility, Otte once witnessed disappointment on the face of a frail elderly woman with dementia and mild diabetes when she got “caught” hiding chocolate bars. It was a simple but polarizing moment for Otte: for that woman, multiple medications and a restrictive diet represented a medical, but not a human, approach.

Perhaps it was the metaphors of the heart that inspired Otte to think about and eventually devote much of her practice to helping patients avoid overdiagnosis and unnecessary care, to that predilection of physicians to solve things, to come up with solutions.

In an effort to move toward one such solution, Otte runs the Less is More Medicine website (www.lessismoremedicine.com). She is an active Clinical Leader with the Choosing Wisely Canada campaign and champion for the broader movement for appropriateness in health care, which incorporates shared decision making and emphasizes patient-centred, evidence-informed practice. As she highlights on her website and in lectures, policy work, and clinical interactions, “More is not always better. Patients and healthcare providers can work together to pursue care that improves health outcomes, all the while minimizing harm and unnecessary interventions. If we avoid testing and treating when it is not needed, we can focus on doing more of the things that really matter.”

Otte hopes for a transformation in medical practice. She works toward this through what she identifies as a 2-tiered process: “A less-is-more-medicine approach involves, first, changing the culture of medicine at a high level and, second, changing the day-to-day way in which physicians and patients interact.” Teaching medical students and residents and speaking at conferences, she aims to inspire others to change their practice.

Providing the tools to do so is essential. Otte’s A New Kind of Rounds events highlight cases in which patients experienced “too much medicine” and she is working to embed Choosing Wisely resources in BC’s Pathways physician resource. Otte also brings the lens of appropriateness to her policy work with the Doctors of BC Council on Health Economics and Policy and the Society of General Practitioners of BC.

Otte believes that it is not only the concept of unnecessary or harmful tests and treatments that needs confronting, but also our unwillingness to have a dialogue about death or to accept death as a natural part of life.

“My dad’s dad was palliated at home. My maternal grandmother died in a quietly spiritual way. She was stoic. She didn’t want any life-prolonging treatments. She just said: ‘I’m ready to go’ and then she passed on. Death is a taboo subject. But there is such a thing as a good death, a death we’re not fighting.”

Otte is quick to observe the tricky and slippery business that is a patient and physician arriving, together, on a decision about when testing and treating might not be needed or desired. Some of her thoughts on that complexity come from years of work in Canada’s Arctic North: “Infection, trauma, and suicide rates are substantially higher in northern, remote communities than in the south. A lot of death happens up there— too much—and people are unquestionably deeply saddened by the loss of loved ones. But it wasn’t necessarily death itself that was upsetting.

“There was a substantive humility about death, a closeness to it, in a way. I don’t know a lot about Inuit culture,” admits Otte, “but it seems to me people were less afraid of death, simply more willing to speak openly about it.”

Otte carries both memories of the far north and a memory of her farming childhood with her as she works toward deeper engagements about what really matters to people, about diagnosis between physicians and patients, about being alive in this world.

PHOTOS (TOP, LEFT TO RIGHT)

Dr Otte on her farm in Nanaimo, BC; surveying the garden in winter with her cat, Sophie; cleaning up for the spring planting; at home with her husband, Ian Reilly.

BOTTOM

Dr Otte enjoying her surroundings while canoeing along the beaver pond in her backyard.

PHOTOS (LEFT)

(Top) Dr Otte working on the Less is More Medicine website; (Bottom) in many instances, less is more.

PHOTOS (RIGHT, TOP DOWN)

The Choosing Wisely Canada (CWC) website; a CWC campaign poster (printed with permission from CWC). Dr Otte listening to a patient; at work in the hospital; joking with Dr Peter Metrowich in the emergency department.

PHOTOGRAPHER

Photos by Cathie Ferguson, Victoria, BC.

Canoeing-along-the-beaver-pond photo by Ian Reilly.

Footnotes

La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2016 à la page e157.
Dr Otte is a practising family physician in Nanaimo, BC, and is Clinical Leader for Choosing Wisely Canada in BC. Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments (visit the website at www.choosingwiselycanada.org). Less is More Medicine is a platform that gathers and shares resources that pertain to appropriateness in medicine, including articles, videos, conference announcements, blog posts, and hands-on tools for direct patient care (visit the website at www.lessismoremedicine.com).
The Cover Project The Faces of Family Medicine project has evolved from individual faces of family medicine in Canada to portraits of physicians and communities across the country grappling with some of the inequities and challenges pervading society. It is our hope that over time this collection of covers and stories will help us to enhance our relationships with our patients in our own communities.