Choosing Wisely Canada recommendations

Family medicine recommendation 1

Do not do imaging for lower back pain unless red flags are present.

Emergency medicine recommendation 3

Do not order lumbosacral (low back) spinal imaging in patients with nontraumatic low back pain who have no red flags.

How have you implemented this recommendation in your practice?

We display posters itemizing the Choosing Wisely emergency medicine¹ and family medicine² recommendations. We have trained our staff to ask red-flag questions before the physician sees the patient, so that we are able to focus on the importance of these features. We have also built 5-minute follow-up appointments into our scheduling system. This allows us to do 3 things: use time as a diagnostic tool, support patients in accepting different ways to manage their symptoms, and avoid low-value investigations that patients might request. We also provide patient handouts.^3,4 They allow patients to understand a bit more, at a time of reflection, about the treatment decision we made together.

How have you brought the Choosing Wisely principles to your relationship with patients?

Choosing Wisely has opened the door to better conversations with patients, especially around their fears. It has been interesting to hear how many people come in and say, “You know, my back has been bothering me. I should get an x-ray.”

You respond, “So tell me why you feel you need an x-ray. What are you worried about?”

They say, “Well, my uncle has prostate cancer and it started with back pain.”

Family and community experiences can have a real influence. So can social media. Patients hear catastrophic stories and they think these stories are the norm. Exploring these fears allows us to provide scientifically based information. I can say, “I hear you and I understand your fears. Here’s what I know about back pain.” This provides balance for the patient.

When I first heard of Choosing Wisely Canada, I went through their list of recommendations^* and found the ones that applied to my practice. I focused on 2 for a couple of weeks, and then focused on another 2 for a couple of weeks. Eventually my new “Choosing Wisely” way of dealing with certain clinical problems became routine.

What does Choosing Wisely mean to you as a family physician?

Choosing Wisely helps me replace superficial conversations with meaningful conversations. It is no longer about, “You want something and I am not giving it to you.” The Choosing Wisely approach is, “I hear you. I respect where you are coming from. And I would like to share with you some other ideas. I don’t want to bring harm to you. I want you to experience good health in every realm.” Patients have agency over their health care decisions and physicians can do certain things to help. Choosing Wisely centres the conversation on mutual understanding, trust, and respect.