Empowering Medical Learners to Choose Wisely
I am a 4th year medical student who spent the last year as a clerk at North York General Hospital, a place that is often referred to as the “poster child” for Choosing Wisely Canada (CWC). In reflecting on this year, one particular instance out of many shifted my entire perspective on what it means to choose wisely.
One morning, in my family medicine clinic, I was reviewing the ultrasound report for a patient who would be returning later that day. The result read “3-4 cm right ovarian cyst, recommend follow up in 6-12 months”. I quickly made a note in the chart and then moved on to other results. However, when I reviewed this with my preceptor, she instinctively said, “Megan, take another look at the report- if it truly is a 3 cm simple cyst- I want you to look into the guidelines for radiology follow up.” Sure enough, I found that the guidelines of the Canadian Association of Radiologists recommended that no follow up is necessary for a simple cyst <5 cm in a premenopausal woman. My preceptor called the radiologist and spoke with him to confirm that it was a simple cyst and to discuss the follow up recommendations. Ultimately, after discussing with the patient as well, we all agreed that no follow up was needed. This prevented an unnecessary testing burden for this patient and unwarranted use of medical resources. But more than that, it showed me the inner workings of an astute clinician’s thought process and actions to reduce medical waste.
There is nothing extraordinary about this particular interaction at first glance but it is a great depiction of the actions that can be taken in everyday practice to choose wisely. I found it particularly poignant because many trainees and physicians, myself included, would have automatically accepted the initial recommendation given. Medical learners often fall into a routine of overuse—in my experience due to lack of time, knowledge, or confidence. In medical school lectures, we are taught facts, diagnoses, and lists of tests that are used to reach those diagnoses. We are rarely, if ever, taken through a thought process around the appropriateness of certain tests. Additionally, the repercussions and burden to patients of unnecessary testing is something left entirely outside of the classroom.
Creating a medical culture that celebrates restraint is the key to teaching learners to be thoughtful and diligent about when care is necessary. It is about teaching trainees to learn to adapt and change with new evidence, and to realize that they should periodically re-evaluate their ordering and prescribing habits. Habit and automatic ordering is at the very crux of our overuse problem. There has been a lot of dialogue around choosing wisely as a physician, but research has very clearly demonstrated that what we learn in our medical training will have a significant impact on our choices as physicians. Furthermore, current medical education environments do little to curb this mentality of overuse.
I was thrilled to have several lecturers in medical school mention the Choosing Wisely recommendations. This was a great way to introduce the topic to students and to promote this mentality early on. As I see it, there are two critical steps in creating change. The first step in fostering change is raising awareness. Given the huge success of the CWC campaign in recent years, I have no doubt that this is very much underway and the integration into the pre-clerkship curriculum is an ideal way to make learners aware. I think the second step—what I would call day-to-day implementation—especially in clinical learning, is where we have work to do. Certainly, good places for students to start learning about the topic are the CWC recommendations for students (which were based on feedback directly from Canadian medical students) and their STARs program. These initiatives have helped to bring our generation of learners into the discussion. The problem is that guidelines remain merely that unless a teaching environment reinforces them.
Two recommendations that can be easily integrated into clinical teaching and learning are:
- Don’t suggest a test, treatment, or procedure that will not change the patient’s clinical course. This is relevant to every patient we see as medical trainees. “Will this change my management?” is a question I ask myself each time I contemplate which tests to order, if any need to be ordered at all.
- Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe are unnecessary. Although the hierarchy of medicine can often be intimidating, having the courage to open a discussion on the necessity of a test with your preceptor can be beneficial for both the student and the teacher. For example, after carefully studying the Canadian CT head guidelines, I would regularly ask my emergency medicine preceptor why she thought a CT head was or was not necessary for patients I saw. As a result, by the end of my rotation we would routinely discuss the necessity of a CT for almost every ambiguous case before proceeding.
It is unfair and inadequate to simply provide the recommendations to our learners and not create a clinical environment that both teaches how to use them and praises students for showing appropriate restraint. In the midst of an overuse crisis, how do we foster a mentality that empowers students to continually question current practices, or better yet, think critically about their own?
I feel confident that medical trainees have a new perspective to bring to the discussion on Choosing Wisely. We, in collaboration with medical educators and physicians, will be critical in implementing change that will lead to the best possible patient care, because ultimately that’s what matters most.
BIO: Megan Woolner is originally from Sault Ste. Marie, Ontario. She is currently a 4th year medical student at the University of Toronto.
