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
Leave a Reply

1000
9 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
8 Comment authors
  Subscribe  
newest oldest
Notify of
Dr. Anil Rickhi

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… Read more »

Kathy Conlin

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… Read more »

Trevor Theman

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… Read more »

John Fernandes

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… Read more »

Trevor Theman

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

I agree.

Richard Schuld

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… Read more »

maria krzywicka

For Dr. Trevor Theman :

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

Andy Pattullo MD, FRCPC

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.