A stitch in time

I always shied away from conflict with my patients until I returned from Africa.¹ Fresh off a 6-month stint in Chad volunteering with Médecins Sans Frontières, I simply could not understand why a parent would not want to vaccinate their newborn child against tetanus. I stopped short of showing vaccine-hesitant parents pictures of what tetanic spasms and rigor looked like, and explaining how the best treatment for these babies was adult doses of benzodiazepines and isolation from sudden noise and light. Even in intensive care units, the survival rate is not much better than it was on the border between Chad’s eastern provinces and the Sudanese region of Darfur.

In that region, we lost about 3 out of 4 babies with neonatal tetanus, and these count among the most heart-wrenching deaths that I have witnessed. Those babies’ parents would have done anything to have themselves and their babies vaccinated.

Suffice to say, some of my first patient consultations in Canada after coming back from the African desert did not go well. Maybe it was my cynicism before channelling my energy into health equity and promotion, or maybe it was just that challenging patients thoughtfully takes practice. This issue of Canadian Family Physician can guide us on how to more constructively have difficult conversations with patients about appropriate care.

Cheng et al (page 726)² remind us there are 3 components to physician workload: necessary clinical tasks, unnecessary clinical tasks, and administrative tasks. As the authors state, 30% of tests and treatments may, in fact, be unnecessary.² How do we approach this?

Assuming the impetus for inappropriate interventions is not our own discomfort with uncertainty, communication skills with patients are key. Cheng et al propose 3 steps to address patient requests for diagnostic tests. The time needed to treat (TNT), which refers to the time required by clinicians to perform an intervention, can also give patients a sense of time burden not just for clinicians, but also themselves.³

Ordering a requested but unindicated x-ray scan of a patient’s back may only take a few minutes. We may subconsciously feel this takes less time than a detailed explanation why the x-ray scan is unlikely to be helpful. However, Cheng et al estimate ordering unindicated x-ray scans of a patient’s back may cost the average clinician 5 weeks of time over a 25-year career,² which is a lot of TNT.

Let us remember that most patient requests are valid, and many go unmet in the health care crisis. Perhaps there is no better example of this, and how unchecked technological divestment can be harmful, than unmet mental health needs. In their thoughtful article, Morkem et al (page 689)⁴ explore how “disorders of despair” are increasingly prevalent in a health system and society not always attuned to the human scale (or even human needs). Research and data are also needed to help us make better decisions.

We know communication works best in longitudinal relationships, but a study by Gabinet-Equihua et al (page 730)⁵ exploring preferences of Canadian patients without a primary care provider (PCP) found a factor ranked very important most often by both those with and without a PCP was “they know me as a person and consider all the factors that affect my health.” However, unassigned patients cease the search for a PCP due to being healthy and not needing a clinician. This requires time to explore with patients.

More of this conversation must occur at societal and basic educational levels, rather than clinical ones. Sixty percent of Canadian adults (and 88% of seniors) are not adequately health literate,⁶ and in a context of diminishing returns of numerous novel interventions for common conditions,⁷ we need a societal conversation about prioritizing care.

When overworked after a long day, I sometimes think of those neonatal babies with tetanus in Chad. I think of their parents, weeping in a dark corner of the hut where we tried our best. Every act in the African desert was measured—with limited resources, we had to maximize success. Invariably, this meant focusing on what mattered most.

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