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Teaching trainees and residents to “Choose Wisely”

René Wittmer, Guylène Thériault and Kimberly Wintemute
Canadian Family Physician October 2019; 65 (10) 754-756;

A report published by the Canadian Institute for Health Information suggests that an estimated 30% of tests, treatments, and procedures in Canada are unnecessary, meaning that they offer no clinical value to patients and can cause harm.1 This is consistent with estimates in many other countries.2

Overuse in health care is a burden to patients and to the health care system. It is associated with harms such as false positives, overdiagnosis, side effects from treatments that might not have been warranted, and medication interactions. Available resources are always limited and need to be allocated wisely. Indeed, the revised CanMEDS–Family Medicine framework includes “engage in the stewardship of health care resources” as one of the key competencies of the leader role.3

Teaching appropriateness

Previously published data indicate that while family medicine residents tend to order appropriate preventive health screening, they also tend to order additional unnecessary tests.4 Research has shown that the residency training environment plays a role in shaping the way physicians practise for years to come. For example, a US study demonstrated that training-site culture influenced whether or not internists were prone to use a conservative approach, when appropriate, without affecting the rate of more aggressive approaches when deemed necessary.5 Changing one’s established practice is difficult for any physician, making our teaching around “appropriateness” of the utmost importance.6 Given these data, it seems essential to create a culture of appropriateness in medical education. The fact that the patient-doctor relationship is at the core of the family physician role makes us ideal champions of initiating conversations about overuse with our patients.

While the means to achieve these goals might vary, a review of educational interventions targeting medical learners suggests that a combination of knowledge transmission, reflective practice, and a supportive environment are key to creating a culture of appropriateness.7

Table 16,8 and Box 19 are teaching tools that can help teach learners the principles of appropriateness; they can be downloaded from https://choosingwiselycanada.org/teachingcw1 and https://choosingwiselycanada.org/teachingcw2, respectively. Consider printing these resources and posting them in teaching rooms for easy reference. The creation of these 2 teaching tools was inspired by the Choosing Wisely Canada poster Four Questions To Ask Your Health Care Provider, available at https://choosingwiselycanada.org/wp-content/uploads/2017/05/Four-questions-EN.pdf, which was distributed to the public and clinicians across Canada to help initiate conversations with clinicians about overuse with the following questions:

  • Do I really need this test, treatment, or procedure?

  • What are the downsides?

  • Are there simpler, safer options?

  • What happens if I do nothing?

View this table:
Table 1.

Examples of activities that teach principles of resource stewardship*

Box 1.

Granular questions to ask learners around appropriateness*

Does this patient need this test?

  • Was it done previously?

  • If so, what is the indication for repeating it?

  • Is the result of a repeat test likely to be substantively different from the last result?

  • If it was done elsewhere, can I get the result instead of repeating it?

  • Did we consider a less invasive option?

Is this test or treatment likely to change the patient’s management? Will it help the patient achieve his or her care goals?

  • What are the goals of care for this patient at this time?

  • What matters to your patient?

Can the patient’s current presentation be the result of side effects from existing medication? Is withdrawing that medication more appropriate than further testing or treatment?

Does the patient embrace the proposed plan? Did we truly integrate his or her viewpoint?

What are the potential harms? Do the advantages outweigh the disadvantages?

Does the patient understand potential risks versus benefits? Do the benefits outweigh the risks for him or her?

What are the effects of potentially labeling this person “sick”?

Are you suggesting this primarily because the patient wants it, for academic reasons, or because your supervisor wants it?

Is the patient in potential danger (in the short term) if you do not perform this test or start this treatment? Is watchful waiting an appropriate alternative?

How certain is the evidence for this test or treatment? Does the evidence apply to this patient?

Could this intervention cause a serious burden to the patient? Practically speaking, how will it affect his or her life?

*This Choosing Wisely Canada “Teaching Trainees and Residents To ‘Choose Wisely’” tool can be downloaded from https://choosingwiselycanada.org/teachingcw2.

Adapted from Choosing Wisely Canada’s list Six Things Medical Students and Trainees Should Question, https://choosingwiselycanada.org/wp-content/uploads/2017/04/Medical-students-and-trainees.pdf, and Laine.9

Conclusion

As teachers, we can foster a better understanding of the usefulness and limitations of tests, treatments, and procedures. Abstract concepts like risk and overdiagnosis require deep understanding and deliberate learning in order to become part of daily clinical care. Beyond resource stewardship, CanMEDS–Family Medicine requires competencies in multiple domains that relate directly to the tenets of Choosing Wisely Canada. Simple strategies can help health care learners to appreciate that sometimes less is more.

Notes

Teaching tips

  • ▸ Overuse in health care is a burden to both patients and the health care system; for this reason, teaching family medicine residents about the “appropriateness” of care is of the utmost importance.

  • ▸ As teachers, we can help residents develop a better understanding of the usefulness and limitations of tests, treatments, and procedures. Abstract concepts like risk and overdiagnosis require deep understanding and deliberate learning in order to become part of daily clinical care.

  • ▸ This article presents tools that provide activities to help teach principles of resource stewardship and that offer a list of questions to ask learners about appropriateness; the tools can be downloaded from https://choosingwiselycanada.org/teachingcw1 and https://choosingwiselycanada.org/teachingcw2, respectively. Consider printing these tools and posting them in teaching rooms for easy reference.

Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Viola Antao, Teaching Moment Coordinator, at viola.antao{at}utoronto.ca.

Footnotes

  • Competing interests

    Dr Wittmer is a member of the Scientific Planning Committee and a course facilitator for Practising Wisely in Quebec. Dr Thériault is Primary Care Co-lead of Choosing Wisely Canada. Dr Wintemute is a member of the Scientific Planning Committee and a course facilitator for Practising Wisely in Ontario, and Primary Care Co-lead of Choosing Wisely Canada.

  • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’octobre 2019 à la page e453.

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Teaching trainees and residents to “Choose Wisely”
René Wittmer, Guylène Thériault, Kimberly Wintemute
Canadian Family Physician Oct 2019, 65 (10) 754-756;
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