Outside of clinical supervision | Include lectures and case discussions on overuse, overdiagnosis, and iatrogenic complications with proposed solutions
Encourage quality improvement projects on reduction of overuse of specific tests or treatments (Choosing Wisely Canada recommendations are a good starting point)
Encourage healthy scepticism regarding published guidelines and underlying evidence
Compare 2 guidelines on a topic, highlighting differences in recommendations Discuss discrepancies between guidelines, asking the following:
-Are patients involved in the guideline development? -Are primary care physicians involved in the guideline development? -Who funds or publishes the guidelines? -What are the authors’ potential conflicts of interest? -What is the strength of the recommendations and the quality of evidence supporting them? -Do the guidelines apply to your patient population?
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During clinical supervision | Encourage regular medication review, tapering or deprescribing when appropriate; consider using guidelines from the Canadian Deprescribing Network8
Talk out loud about whether a proposed test, treatment, or procedure will truly affect patient outcome
Ask learners if a conservative approach might be just as appropriate as an interventional approach
Integrate feedback alerts in your EMR for redundant testing
Integrate nudges for certain commonly overused high-risk medications or for certain tests of little value
Encourage learners to watch for inappropriate care; encourage them to point out these situations. Give them approaches for how to discuss these concepts with other preceptors
Modify SOAP note format to include a review of appropriateness (medications, testing)
Model and encourage shared decision making, using tools where available
Acknowledge areas of uncertainty and gaps in knowledge, and how to disclose this to patients
Be a role model in terms of judicious use of tests and treatments. Research has shown that residents who order “excessively” sometimes perceive such expectations from supervisors6 |
In feedback and evaluations | Include a section on appropriate use of tests and treatments on daily feedback sheets
In formal written examinations or OSCEs, integrate questions on appropriateness, polypharmacy, deprescribing, management of side effects, or complications of treatments |