Choosing Wisely Canada recommendations

Family medicine recommendations 5 and 10

Do not do annual screening blood tests unless they are directly indicated by the risk profile of the patient; and do not advise non–insulin-requiring patients with diabetes to routinely self-monitor blood glucose levels between office visits.

How have you implemented these recommendations in your practice?

Currently I am focusing on diabetes: both the screening of patients as well as glucose self-monitoring in patients who do not require insulin.

Choosing Wisely recommends not doing annual screening blood tests—such as hemoglobin A_1c level, which is used to help diagnose diabetes—unless they are directly indicated by the risk profile of the patients. The Canadian Task Force on Preventive Health Care has a great resource, the FINDRISC (Finnish Diabetes Risk Score) table,¹ that I use to assess patients. It helps me to stratify the risk of the patient as low to moderate, high, or very high. Additionally, I can gauge who is an appropriate candidate for blood testing and who will not benefit.

In addition to screening, our non–insulin-requiring patients with diabetes were happy to see us adopt Choosing Wisely practices and to not be testing themselves routinely between office visits. Patients with diabetes understand this recommendation and we have integrated it into their care. Testing yourself frequently is very expensive, especially if you have to do it 4 times a day, and a hundred times a month! It is also harmful to patients, as it is very taxing on their fingers.

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

Choosing Wisely is largely about shared decision making, and about patients and clinicians engaging in conversations about what is necessary together. By using point-of-care tools in my practice, I am able to have very targeted, informed discussions with patients where the evidence and recommendations are all at hand. I used to overtest for diabetes, as I did not have a simple evidence-based way of assessing who was appropriate to test. For example, I would see a healthy 28-year-old woman who had had gestational diabetes. I would think, “How frequently should I test her? Do I really need to do it every year?” With the FINDRISC table, I assess patients within a few minutes and we have a bit of a laugh. If they have any questions or concerns I can answer them while they are in the office, and not necessarily send them for bloodwork every time. Because this is shared decision making, patients have been involved in the process. I am not flipping a coin to determine their care, and patients see that. We are coming to a rational decision together, based on their risk factors.

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

It reminds me that health care is a collective effort between providers and patients. The campaign is well informed and highlights the problem of overdiagnosis. It makes it easy to have conversations with patients about what is necessary. Before campaigns like Choosing Wisely or the continuing professional development course Practising Wisely,^* which is new to Quebec, I did not have many tools or handouts to use in practice. Now I have several resources, as well as websites I can recommend to patients that help supplement what we are talking about in the examination room.

As a teacher, I also use Choosing Wisely with my residents. I share with my students all of the recommendations² from other specialties that apply to family medicine, and we apply them in patient care. Integrating Choosing Wisely into medical education is very important in changing the culture. Some of my students have never heard of Choosing Wisely and do not think of things like overuse or overdiagnosis as part of their training. I am trying to change that.