Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Article CommentaryCommentary

Negotiating “unnecessary”

Microclinical, macropolitical, and coproduction approaches to defining necessity in care

Myles Leslie, Akram Khayatzadeh-Mahani, Charles Webb and Granger Avery
Canadian Family Physician August 2018, 64 (8) 562-563;
Myles Leslie
Assistant Professor in the Department of Community Health Sciences in the Cumming School of Medicine and Associate Director of Research in the School of Public Policy at the University of Calgary in Alberta.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: myles.leslie@ucalgary.ca
Akram Khayatzadeh-Mahani
Research Associate in the School of Public Policy at the University of Calgary.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Charles Webb
Family physician in Vancouver, BC, and President of the Vancouver Medical Association.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Granger Avery
Family physician in Port McNeill, BC, and Past President of the Canadian Medical Association.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

In April 2017, the Canadian Institute for Health Information, together with Choosing Wisely Canada, released a report entitled “Unnecessary Care in Canada.”1 This first ever national report echoes findings in other jurisdictions2,3 as it tracks a key element in the global drive to reduce per capita costs while improving quality.4 The Canadian numbers suggest that up to 30% of selected tests, procedures, and treatments are unnecessary, if not outright harmful. The report’s authors add specific details—for example, 1 in 10 Canadian seniors takes a sedative-hypnotic sleep aid regularly1—and argue that unnecessary care is contributing to losses at both economic and outcome levels. As we have seen elsewhere, there is money to be saved and quality to be improved in ridding the system of unnecessary care. The devil, as always, is in the details. Specifically, in the microclinical and macropolitical interactions where “unnecessary” is determined.

Mismatches between opinions and data in daily clinical practice

At the micro level, in daily clinical practice, we routinely encounter patients whose value-for-money expectations, self-diagnoses, or attention seeking lead to compromise requisitions or prescriptions for magnetic resonance imaging, antibiotics, or even opioid analgesics. Do some colleagues stickhandle a demand for magnetic resonance imaging down to less-expensive computed tomography? Yes. Do some colleagues summon up exactly the right argument at exactly the right time to counter an expected antibiotic prescription? Certainly. But there are just as certainly some of us who are unsure or who choose discretion as the better part of valour in these ongoing microbattles to define what is, and what is not, necessary.5 In the absence of high-quality evidence, applicable evidence, or any evidence at all, many of these struggles to define necessity in care are resolved using a “common sense” that emerges from the expertise and experiences of physicians and patients engaged in conversation.

These observations are intended neither to blame patients for what they bring to the clinical encounter, nor to exhort physicians to be more rigid. Rather, our point is that there can often be a mismatch in the opinions and data that patients and physicians bring to determining necessity. On the one hand there are patients’ individual personalities and culturally informed expectations of care and on the other, physicians’ personalities, work flows, and a scientific evidence base. As the realities of everyday clinical work suggest, that evidence base is but one of many opinions and data sources brought to bear as we negotiate necessity. The authority of the evidence base—its power to persuade—hinges on the status of science and facts at a broader political level.

Public debate in a time of polarized engagement

Perversely, here at the macro level, we find ourselves with a familiar mismatch of opinions and data. With public trust in expertise6 and government7 at an all-time low,8 and “alternative facts” apparently playing as important a role in public debate and decision making as any other facts, how does the broader politics of necessity proceed? As at the clinical level, sometimes we wait to make what we think is the right argument at what we think is the right time. In this light, consider Schein and Pronovost’s recent assessment of the evidence for preoperative tests for cataract patients. Their study clearly shows no outcome benefits for patients and a potential yearly savings of $500 million (US) if the tests are abandoned.2 However, this is not the first time this evidence has been used in an attempt to define necessity and influence practice. Schein and colleagues’ original study9 appeared nearly 2 decades ago. And so, in the emerging consensus of the macro-level scientific process, we see the same dodges, feints, parries, and thrusts of everyday clinical encounters. Where Schein and Pronovost have taken on—we hope with success—a particular set of tests, there are similar stories of waste to be avoided and outcomes to be improved in treatments and procedures.

But how, in a world of contested evidence and emerging science, do we improve our ability to make convincing arguments? Defining necessity by adding to the peer-reviewed evidence base might still be necessary, but it is no longer sufficient. Where the instinct here might be to double down on these familiar methods—as journalists have, fact checking ever more closely and deeply—there is a complementary approach that operates independently of the assumption that more scientific evidence will succeed where less has not.

Engaging the community

In the early 1990s, the Dunning Commission submitted its final report to the Dutch government, and in it came the recommendation that a “community-oriented approach” be taken to determining which processes, procedures, and service lines were necessary and unnecessary.10 Less than a decade later the World Health Organization rebooted its medical education and clinical practice newsletter to deal with the challenges of health system reform, and in doing so refined the community-oriented approach. The partnership pentagon introduced in that issue shows “the community” to be 1 of 5 key actors that must convene if unity of purpose and action toward high quality, equity, relevance, and cost effectiveness are to be achieved.11 Seventeen years later, at the end of the evidence-based era of public policy,12 this sort of radical democratization of the health care system seems not only promising, but also a necessary complement to producing further scientific evidence.

Here we are firmly in support of Born and colleagues, who call for not just patient engagement but public engagement in the Choosing Wisely program.13 This, along with Légaré and colleagues’ vision of “increasing involvement of patients and the public in co-designing the Choosing Wisely recommendations,”14 is central. The model for this engagement—this shared decision making at not just the clinical level, but the policy level—needs, however, to go beyond a few select patients contributing to lists of recommendations of things clinicians and patients should question. Rather, it must be conducted as a 5-way conversation born out of alliances and synergies “among key interest groups with specific strengths and expectations.”11

Engaging patients and citizens has been shown to be more than an ethical imperative.15 There is hard evidence showing the efficacy of inclusivity and shared decision making at the policy level.16 As we take up the challenge of defining necessity in care in collaboration with patients and the public, we need to follow home-grown examples that have successfully combined evidence with the opinions and perspectives of clinicians and patients to create policy change.17,18 Canada has built substantial capacity in the field with institutions like the Centre of Excellence on Partnership with Patients and the Public at the University of Montreal in Quebec, the Public and Patient Engagement Research-Practice Collaborative at McMaster University in Hamilton, Ont, and the Patient and Community Engagement Research group at the University of Calgary in Alberta. What remains is for us to leverage these resources and the experience of their staff and patient partners as we take on the challenge of defining necessity in care.

Fostering common understanding

The engagement forums, techniques, and community-based research programs that these centres specialize in represent the best channels both for hard-won scientific evidence to be heard and for even-harder-to-find consensus to emerge. While the data are important, the key point here is that they are coproduced and engaged with by a range of parties. Engaging patients and citizens in the decision-making and consensus-building processes is critical, not just so they can better understand the scientific evidence, but also so scientists and politicians can better understand and accommodate how the public defines necessity. Leveraging the capacities of Canadian institutions that specialize in public engagement in health policy is, we suggest, the best way to escape the impasse of current approaches to defining necessity. Rather than perpetuating the polarized shouting matches that can characterize “engagement” on topics like vaccination or fluoridation, these institutions have the methods and experience to draw out truly engaged conversations. Their talents lie in re-creating, at the macro level, the microclinical moment where common sense emerges from a common understanding of a problem.

In the present era of contested facts and polarized engagement, it is only out of coproduced opinions and data that an authoritative and reliable evidence base will emerge. To achieve common definitions of necessity— definitions that hold under the strain of clinical interactions—we need to commit to these coproduction efforts. As “working with patients to reach common ground on the definition of problems”19 is a core skill of Canada’s family practitioners, we are in a position to lead. Given that patient-engaged policy making enhances a sense of ownership, improves accountability, and encourages the uptake of decisions,20 all that remains is for us to commit resources to, and participate in, the codefinition of what is necessary in care.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

  • This article has been peer reviewed.

  • Cet article se trouve aussi en français à la page 564.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Choosing Wisely Canada, Canadian Institute for Health Information
    . Unnecessary care in Canada. Ottawa, ON: Canadian Institute for Health Information; 2017.
  2. 2.↵
    1. Schein OD,
    2. Pronovost PJ
    . A preoperative medical history and physical should not be a requirement for all cataract patients. J Gen Intern Med 2017;32(7):813-4.
    OpenUrl
  3. 3.↵
    1. Van der Wees PJ,
    2. Wammes JJG,
    3. Westert GP,
    4. Jeurissen PPT
    . The relationship between the scope of essential health benefits and statutory financing: an international comparison across eight European countries. Int J Health Policy Manag 2016;5(1):13-22.
    OpenUrl
  4. 4.↵
    1. Berwick DM,
    2. Nolan TW,
    3. Whittington J
    . The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27(3):759-69.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Zikmund-Fisher BJ,
    2. Kullgren JT,
    3. Fagerlin A,
    4. Klamerus ML,
    5. Bernstein SJ,
    6. Kerr EA
    . Perceived barriers to implementing individual Choosing Wisely® recommendations in two national surveys of primary care providers. J Gen Intern Med 2017;32(2):210-7. Epub 2016 Sep 6.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Frank A
    . Why expertise matters [blog]. 13.7 2017 Apr 7. Available from: www.npr.org/sections/13.7/2017/04/07/522992390/why-expertise-matters. Accessed 2018 Jun 12.
  7. 7.↵
    1. Majority of Canadians distrust government: poll suggests
    . CBC Radio. 2017 Feb 16. Available from: www.cbc.ca/radio/thecurrent/the-current-for-february-16-2017-1.3984460/majority-of-canadians-distrust-government-poll-suggests-1.3984577. Accessed 2017 May 1.
  8. 8.↵
    1. Edelman Trust Barometer
    . Trust in Canada. Edelman; 2017. www.edelman.com/trust2017/trust-in-canada. Accessed 2017 May 2.
  9. 9.↵
    1. Schein OD,
    2. Katz J,
    3. Bass EB,
    4. Tielsch JM,
    5. Lubomski LH,
    6. Feldman MA,
    7. et al
    . The value of routine pre-operative medical testing before cataract surgery. N Engl J Med 2000;342(3):168-75.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Hermans H,
    2. den Exter A
    . Priorities and priority-setting in health care in the Netherlands. Croat Med J 1998;39(3):346-55.
    OpenUrlPubMed
  11. 11.↵
    1. Boelen C
    . Towards unity for health. Challenges and opportunities for partnership in health development. Geneva, Switz: World Health Organization; 2000.
  12. 12.↵
    1. Forest PG,
    2. Helms WD
    . State policy capacity and leadership for health reform. New York, NY: Milbank Memorial Fund; 2017.
  13. 13.↵
    1. Born KB,
    2. Coulter A,
    3. Han A,
    4. Ellen M,
    5. Peul W,
    6. Myres P,
    7. et al
    . Engaging patients and the public in Choosing Wisely. BMJ Qual Saf 2017;26(8):687-91. Epub 2017 Jun 9.
    OpenUrlFREE Full Text
  14. 14.↵
    1. Légaré F,
    2. Stacey D,
    3. Forest PG,
    4. Coutu MF,
    5. Archambault P,
    6. Boland L,
    7. et al
    . Milestones, barriers and beacons: shared decision making in Canada inches ahead. Z Evid Fortbild Qual Gesundhwes 2017;123–124:23-7. Epub 2017 May 20.
    OpenUrl
  15. 15.↵
    1. Naylor D,
    2. Girard F,
    3. Mintz J,
    4. Fraser N,
    5. Jenkins T,
    6. Power C
    . Unleashing innovation: excellent healthcare for Canada. Report of the Advisory Panel on Healthcare Innovation. Ottawa, ON: Health Canada; 2015.
  16. 16.↵
    1. Boivin A,
    2. Lehoux P,
    3. Lacombe R,
    4. Burgers J,
    5. Grol R
    . Involving patients in setting priorities for healthcare improvement: a cluster randomized trial. Implement Sci 2014;9:24. Epub 2014 Feb 20.
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. South East Community Care Access Centre and Hospital Executive Forum
    . Development of a sustainable integrated model of hospital care. Phase 1 recommendations report. Health Care Tomorrow— Hospital Services Planning; 2015. Available from: http://healthcaretomorrow.ca/wp-content/uploads/2015/07/HCT-Phase-1-Recommendations-Report-FINAL.pdf. Accessed 2018 Jun 12.
  18. 18.↵
    1. Alberta Health Services
    . Patient engagement in support of SCNs [website]. Edmonton, AB: Alberta Health Services.; Available from: https://www.albertahealthservices.ca/info/Page11233.aspx. Accessed 2017 Jun 1.
  19. 19.↵
    1. College of Family Physicians of Canada
    . Four principles of family medicine. Mississauga, ON: College of Family Physicians of Canada; 2006. Available from: www.cfpc.ca/Principles. Accessed 2017 Jun 1.
  20. 20.↵
    1. Wallerstein N,
    2. Minkler M,
    3. Carter-Edwards L,
    4. Avila M,
    5. Sánchez V
    . Improving health through community engagement, community organization, and community building. In: Glanz K, Rimer BK, Viswanath k, editors. Health behavior. Theory, research and practice. 5th ed. Hoboken, NJ: Jossey-Bass; 2015. p. 277-300.
PreviousNext
Back to top

In this issue

Canadian Family Physician: 64 (8)
Canadian Family Physician
Vol. 64, Issue 8
1 Aug 2018
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Negotiating “unnecessary”
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Negotiating “unnecessary”
Myles Leslie, Akram Khayatzadeh-Mahani, Charles Webb, Granger Avery
Canadian Family Physician Aug 2018, 64 (8) 562-563;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Negotiating “unnecessary”
Myles Leslie, Akram Khayatzadeh-Mahani, Charles Webb, Granger Avery
Canadian Family Physician Aug 2018, 64 (8) 562-563;
Reddit logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Mismatches between opinions and data in daily clinical practice
    • Public debate in a time of polarized engagement
    • Engaging the community
    • Fostering common understanding
    • Footnotes
    • References
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • Négocier « l’inutile »
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Collaborative mental health care
  • Big ideas
  • Our role in making the Canadian health care system one of the world’s best
Show more Commentary

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • RSS Feeds

Copyright © 2023 by The College of Family Physicians of Canada

Powered by HighWire