Trevor’s Take: On getting value from medical care

Dina Baras CPSA, Messenger, Trevor's Take On 9 Comments

Good stuff is happening in health care in Alberta. I see this from my various perches, as a member of various health committees, from conversations with leadership in Alberta Health Services, the Ministry of Health and other professions, the Alberta Medical Association, and from the leadership team at the CPSA.

There is common recognition of the importance of strong, high quality primary care in Alberta, support for the evolution of Primary Care Networks, approval by Government for the AHS Clinical Information System (CIS) and, perhaps most importantly, openness and cooperation among the participants, most notably from the Ministry of Health.

I’ve been in this job for nearly 12 years and it’s only in the past couple of years that I’ve seen actual cooperation and sharing by Government. For me, this attitudinal change began with Medical Assistance in Dying (MAiD) and has continued from there. MAiD was, in my tenure, the first time that Government suggested we cooperate from the beginning, sharing ideas and plans. In time, AHS and our sister Colleges of Pharmacy and Nursing were included, and MAiD, in spite of its complexities, has been rolled out more smoothly in Alberta than any other jurisdiction in Canada; the willingness to share and solve problems together has been the key to success.

There is now broad representation on the senior health information committees in Alberta, and on the Physician Resource Planning Committee. Work is underway on both provider and patient registries, and PCN 2.0 is progressing.

These are all essential elements to the reform of Alberta’s healthcare system or, perhaps more correctly, to the creation of an integrated healthcare system in Alberta.

There is one critical element essential to the success of this grand venture, and that is the commitment and attention of physicians – individually and in groups – to sign on, to align their work and practices with the needs of Albertans and with the system-at-large.

 

A couple of examples to illustrate my point:

  • Currently about 40% of PCN physicians across Alberta have patient panels whereas we need that to be 100%, in part because understanding one’s panel and the healthcare needs of that population is essential to providing the needed services to the population served
  • While the prescription opioid crisis may have plateaued in absolute numbers, hundreds of Albertans remain on unsafe doses of opioids, often in combination with other opioids and/or other drugs, such as benzodiazepines. This problem can be solved only by every physician recognizing his/her role in this crisis, and by working hard to limit the use of opioids, whether in the ER, following surgery or for patients with chronically painful conditions.
  • Choosing Wisely is laudable but, in my estimation, it plays too much around the edges of medical practice, and doesn’t address broad over-utilization and indiscriminate use of investigations. Recently inspectors of a cardiac exercise stress test facility reviewed 10 charts, all properly completed and clearly reported, 9 of which had inadequate indications. That is, 9 of the 10 patients referred for a cardiac exercise stress test should not have been referred (a problem on the referral side); and 9 of the 10 patients shouldn’t have had the test performed (a problem on the consultation side), as the pretest probability of ischemic heart disease was too low. There are lots of similar examples in diagnostic imaging and laboratory investigations. Every physician owns this problem, no matter which side of the referral/consultation process you’re on.
  • Every physician needs to have an EMR, access to Netcare and PIN, and the ability to share/push a defined data element set to the provincial clinical information system. Not only is this information necessary to the health system, access to the information housed within Netcare and PIN is often essential to providing good care to patients, and is a requirement now (CPSA Standard of Practice) when prescribing opioids.

Understanding what needs to happen seems not contentious; how to achieve these ends is vexing and unclear, however. To me the best solution is a local one; individuals and groups of physicians (a practice, a PCN, a department, a partnership) asking how they can ensure the public receives value from the services they provide.

Are we doing the right things? Why is there such variability in practice between physicians in the same clinic or department? Are we compliant with the expectations of the College of Physicians & Surgeons of Alberta, as set out in the Standards of Practice?

Asking the questions is a critical first step, but there must also be a commitment to act, to improve, to reduce variation in practice and to rein in the outliers. In this approach, outliers can only be reined in if they agree to cooperate, to be coached and to be monitored. Is this approach likely to be successful? I don’t know, but I know these two things: it has to happen (current practice is too expensive to ignore); and practising good medicine, high quality medicine, will be a lot more satisfying and valuable for everyone.

 

From time to time College staff are asked by physicians what should I do with a request to (pick from the following menu):

  • Order a battery of tests recommended by another practitioner, none of which I believe are indicated?
  • Refer a patient to a therapy, covered financially by the patient’s employer, when I don’t believe it will be helpful?
  • Complete a disability form with this exact wording, even though I don’t support or agree with what I’m asked to write?

In all cases the approach and the answer is the same. Do what you believe is right, is indicated and is supported by evidence. These are excellent examples that highlight the fundamental responsibilities in our Code of Ethics:

  • Practice the art and science of medicine competently, with integrity and without impairment, and
  • Resist any influence or interference that could undermine your professional integrity

Integrity is the key word in both.

 

Trevor Theman

9 Comments on Trevor’s Take: On getting value from medical care

Dr. Anil Rickhi said : Subscribe May 21, 2017 at 8:36 AM

Thank you Dr. Theman,

  Your messenger article is very insightful and certainly articulates many of the needs and concerns physicians have with respect improving patient care. I agree that unwarranted medical tests/screening are detrimental to AHS and the Province in general. 

As an example, with Vitamin D screening, I reclently called ALS to inquire about the cost and was frankly disconcerted and shocked about how much this test actually costs. My belief is that the evidence needs to support the ordering of a lab/screening test. However, I feel that many of us are not informed and the blame cannot be put on the physician alone as it is our mandate to provide the best service to patients. We simply need more education around these issues. 

However, Frankly I agree with Dr. Schultz and can appreciate his perspective. If a referral for a patient is received should he have to phone every family physician or whomever made the referral to ensure the test is warranted? This would likely lead to further expenses and increased wait times for patients. I believe we are dancing around an important issue that being primary prevention. 

I don't believe the ordering of lab tests is so black and white. While I agree with Dr. Theman that the art and science behind medicine needs to be combined clinical judgment should be part of the equation. 

To be blunt, many physicians relying on their clinical judgement may order an HBA1C in the the best interest of their patient as we all know that the treatment, cost, morbidity and mortality of type 2 diabetes is and will keep increasing.

Personally, I would rather see a patient screened for this and have the necessary medical preventions put into place to prevent a disease so that the internal medical wards are not slammed with patients with retinopathy, peripheral neuropathy etc..that adds an extreme cost to the health care system vs screening and primary/secondary prevention.

 

 

 

 

 

Kathy Conlin said : Subscribe May 17, 2017 at 7:36 PM

Mr. Theman,

I agree that there are a lot of good things happening in Health Care in Alberta.  I also agree with the 2 principles you referred to in the Code of Ethics and how integrity is a key word in both; however, accountability is also critical.  As professionals, physicians must be held to a higher standard and must follow the standards of practice of the CPSA.  If all physicians adhered to these standards, I would venture to say or even argue that there would not be such a great variability in practice between physicians.  The outliers must be reined in as you say.  Unfortunately, physicians are human and may not always follow the standards as required but that is where the CPSA comes in.  The College is an important governing body and must make sure physicians follow the standards of practice despite the challenge of governing over 10,000 physicians in this province - most who are now part of the PCN.  It is without a doubt a huge challenge, but I truly believe that the CPSA is up for it given your high standards, ethical and moral compass, and great leadership as registrar over the past few years.   I firmly believe that one must never lose sight of the CPSA's vision, or what I would describe as an mandate, to ensure that the public receives safe, ethical, and equitable health care that reflects the high standards of care physicians must not only aspire to but adhere to as professionals.  Thank you.

Trevor Theman said : Subscribe May 12, 2017 at 4:24 PM

Screening, by definition, is the searching for disease (or markers of disease) in an asymptomatic population. The use of mammographic screening in asymptomatic women aged 50 to 70 is an example. Screening is not the conducting of diagnostic testing in patients with symptoms or signs of disease.

I will let others defend Choosing Wisely.

My commentary highlighted an example of unjustified testing - cardiac exercise stress testing in a number of patients where the predictive value is simply too low. The intent is to have members of the profession be more careful about the use of investigations and to use their knowledge of the evidence behind both screening and the limitations of other forms of testing in their clinical decision-making.

We should not ignore the negative effects of poorly considered investigations, only one of which is cost. 

 

 

John Fernandes said : Subscribe May 11, 2017 at 10:53 PM

These are interesting comments, and bring up some very important issues.  It is gratifying to note that a variety of perspectives and identified responsibilities are being recognized.  

A note of caution, however, is also worth considering.  Physicians are at risk of misinterpreting the "choosing wisely" campaign to simply leave the playing field and "do nothing".  

The "choosing wisely" campaign seems to urge Physicians to "do nothing", including  "avoiding screening" of all kinds of terrible disease processes that are treatable early in the disease processes. 

I have lost count of how many women under the age of 40 that I have been able to save from breast cancer that would certainly have been dead had I adhered to the "choosing wisely algorithms".  The same goes for men under the age of 55 with prostate cancer and the numerous ovarian, cervical, kidney, lung and bowel cancers I have detected through the relatively rigorous annual medicals I perform on my patient population.

The "choosing wisely" campaign seems to castigate the excellent practice of preventative screening that has been touted and supported through previous decades of supportive literature and medical practice. 

Now, Government agencies seem to be in full-blown panic mode to slow their debt monsters and to recruit various agencies like Alberta Health and the CPSA to support "choosing wisely" campaigns.

My concern is that the "choose wisely" moniker that is being pushed on Physicians with all kinds of re-manipulated statistical treatments in favour of the concept, needs to be a finished statement in order to be really honest; in other words...."choosing wisely"......"for who?"....

I am concerned that the REAL statement can all too often be finished with honesty only by saying "Choosing wisely for Government Balance Sheets (please forget all the previous decades of drivel we hammered at you regarding the importance of screening)".

I certainly sympathize with the increasing challenge of answering a seemingly infinite demand for increasingly limited health care resources - the very definition of economics.  

LOTS of "choosing wisely" has to happen - but to actively scare and discourage screening at the cost of "only a few lives" in my opinion, potentially violates the morals and values of our profession.

I am not sure that the CPSA realizes how the overly aggressive or inadequately explained "choosing wisely" campaign that it has been supporting, has been getting increasingly misinterpreted to the cost of patient well being.

The "Choosing Wisely" campaign also serves to lower the morale of too many fine Physicians that insist on "choosing wisely"....."for their patients".

How many abdominal ultrasounds are worth doing in order to find various cancers? What is the optimal "NNT" (numbers needed to treat) integer that society will find acceptable in terms of screening tests?

There are no "correct" answers to such questions, as Government will ALWAYS be at odds with the individual over such matters, and those who face premature morbidity or mortality as a result of having been "chosen wisely" will condemn the practice from their own perspectives.

Some questions are easy to answer: should each member of the population get an annual contrast-enhanced total body MRI?  Of course not.  It is impossible and impractical.

But now let's move down the scale....how about an annual abdominal ultrasound?  

Much more difficult to answer.  

It depends upon all kinds of perspectives.  

Ultimately, it is a Physician/patient decision that relies on the clinical skills, experience and judgement of the Physician.  

 

And it should be left at that.

 

 

 

 

Trevor Theman said : Subscribe May 11, 2017 at 4:16 PM

I am surprised by Dr. Schuld's comments.

Cardiac exercise stress testing is a diagnostic test, not a screening test. It has a financial cost to the health system directly (for the test) and for the additional testing that false positives create. Doing unnecessary testing is not benign, and remuneration is not an acceptable reason for acceding to a request for an unnecessary test.

Primum non nocere.

 

 

Kevin Hildebrand said : Subscribe May 11, 2017 at 2:58 PM

I agree.

Richard Schuld said : Subscribe May 11, 2017 at 2:47 PM

Your comments re the stress test facility are unsurprising. A stress test facility is designed to do stress tests, and by definition does not screen, because doing these tests are how money(or just a living) is made. A proper medical consultation, however, is more expensive. Is mass screening - for that is what this is - more or less expensive than mass specialty consultation? Are the 5-10% abnormals requiring more investigation, or change in therapy well worth the cost of this mass screening - or not? What if such a test is dictated as part of employment by an outside agency? I realize that these agencies pay, but use up the same facility, time, cognition of the examiner. Would limiting testing make us healthier, or just slow the economy?

maria krzywicka said : Subscribe May 11, 2017 at 11:47 AM

For Dr. Trevor Theman :

This is one, perhaps the best one of your all TAKES.

Andy Pattullo MD, FRCPC said : Subscribe May 11, 2017 at 11:04 AM

I find this a very insightful, appropriate and timely post. IT nicely outlines some of the major issues in healthcare for Albertans that can and must be resolved. Thanks for saying what needs saying.

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