Choosing Wisely Canada recommendations

Internal medicine recommendation 5

Do not routinely perform preoperative testing (such as chest x-ray scans, echocardiograms, or cardiac stress tests) for patients undergoing low-risk surgeries.

How have you implemented this recommendation in your practice?

At our regional hospital, the preoperative process is that patients have an appointment with their family physicians a week before surgery for an examination and a review of their histories. Preoperative tests are ordered at this point, if necessary. Two years ago our local hospital tried to move toward a model of standard preoperative testing that meant chest x-ray scans, echocardiograms, and a litany of blood tests would be done in most patients, even if the patient and the surgery were both low risk. When this new policy was being implemented I, along with others in my family practice and in the community, insisted that preoperative testing had to be individualized and a blanket solution was not appropriate. Risk factors and patient comorbidities should be the indicators that drive testing, not a “let’s check everything just in case” model.

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

First off, I do not let my patients book complete physicals. We need to make the decision together about what tests and treatments are right for their risk factors, if they have any, and proceed from there. So, when my patients come in for preoperative testing before low-risk surgery, some of them know the type of conversation they can expect to have with me. If you are a young, healthy woman, we will do a urine test to make sure you are not pregnant before your surgery, but that could very well be the only test we do. If patients have histories of cardiac disease or are elderly and taking several medications, I will order an echocardiogram and renal function tests before surgery.

A lot of patients are surprised that they do not need testing before low-risk surgery, but they are not upset. I think they understand once we have had a comprehensive conversation about why I am not going to order particular tests or why we pick some tests and not others. If there is push back from patients, we need to take into account psychosocial factors and ask questions such as “What is it that you’re worried about?” or “Why do you feel this way?” This culture of “making sure everything is okay” in medicine is often synonymous with “let’s do a bunch of blood tests,” but making sure everything is okay can also be a conversation. The enduring, trusting relationship we build with our patients is critical to Choosing Wisely. The easy thing for me to do would be to just order the tests with a stroke of my pen. Choosing Wisely takes a lot of commitment on the part of the physician; it is an important component of the necessary culture change in medicine—dedicating time to thoroughly explain to patients why we are, or are not, pursuing tests and treatments.

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

I am fairly new to practice and I remember being taught in residency to only perform testing for questions I needed answers to. Being accountable for or being able to justify each test ordered—and how it would help my patient—is very much in line with Choosing Wisely to me. But once I began to practise I saw many physicians ordering tests that would not provide them with useful information. So, when the hospital administration tried to promote standard preoperative testing for most patients, I saw there was serious potential for this push to not be questioned by other physicians and I became very passionate about the cause.

I pressed my colleagues to think critically about the way they were practising and to justify tests they were ordering for each patient, like when I was a resident. I talked to them about the potential waste of time and resources the suggested model of testing would produce, and also the potential harm and cascade of investigations it could expose our patients to. We decided to push back. As a result, we do not do standard preoperative testing for low-risk surgeries at our local hospital.

To me, Choosing Wisely is about knowing that conversations with patients take time, only ordering tests that will give you the answers you need, and ensuring you work as a team with your colleagues.