Choosing Wisely Canada recommendations

Family medicine recommendation 1

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

What shared decision making strategies or tools have you implemented in your practice for this recommendation?

Discussing LBP with patients is common and often involves challenging patient expectations. I use the FIFE (feelings, ideas, function, and expectations) approach, and I encourage my colleagues and trainees to “FIFE it up” because we can never go wrong with these values. When a patient shares concerns about LBP, I look for every opportunity to discuss the best evidence. This is a powerful way to engage a patient in self-management.

To guide these conversations I use the Centre for Effective Practice’s resources, which include tools and education modules that help primary care providers better manage patients who live with common conditions, including LBP. Specifically, I use the CORE (Clinically Organized Relevant Exam) Back Tool (www.thewellhealth.ca/wp-content/uploads/2016/04/CEP_CoreBackTool_2016-1.pdf), which is endorsed by the College of Family Physicians of Canada.^* This tool helps me to reach the ultimate goal of my conversation: to enhance the care of patients with LBP, while avoiding unnecessary diagnostic tests.

Patients often value participating in analyzing best evidence and its relevance to their problem. They might not be aware that some tests or treatments potentially cause harm. Whenever I have the opportunity I invite patients to integrate evidence into their decisions and care plans. This transparent communication style helps me build consensus with them and leads to improved outcomes for the patient, who is obviously in discomfort.

The typical 15-minute appointment is not a lot of time for these complicated conversations. But with practice, I am now able to go over the CORE Back Tool, demonstrate exercises, and take my notes during the encounter. You need to have these conversations consistently in order to master them.

What makes shared decision making around this topic challenging or rewarding?

Patients are confused by the overload of information on the Internet and in the media with aggressive pharmaceutical marketing. Sometimes the encounter is complicated by the patient asking for a test or treatment that is in direct conflict with best evidence. Having a tool like the CORE Back Tool outlining the “red flags” and showing simple graphics of treatment methods reassures patients. This caring approach improves the patient-provider experience.

It is rewarding to motivate patients to be part of their own care plans; LBP is one of the best examples of this. Patients who are committed to changing old habits and to becoming more active see results. And we have an ideal opportunity to live the values of our speciality.

Why is shared decision making around this recommendation or clinical topic essential to you?

Finding good practical resources to help us manage LBP is a constant challenge and more so in rural practice. Practising shared decision making and using good evidence-based tools such as the CORE Back Tool have helped me demonstrate my passion for rural family medicine and its value as a career choice for young FPs. This in turn has stimulated many of them to elect a career in rural medicine. For me personally, that is a blessed opportunity and Choosing Wisely enriches this experience.

I have spent my entire 27-year career in underserviced areas. At times I feel like an extension of the community or a reliable friend in times of need. Having practical best-practice resources to manage LBP has helped me a lot in my journey to be that trusted friend and support to my patients. In life, for me, there is no greater reward.