Do and do not do: Choosing Wisely

Choosing Wisely Canada is the brand name of a campaign to ensure high quality medical care. One of their current publications lists 13 tests and treatments that family physicians and patients should question. The list may be long on logic but I think it is a bit short on wisdom—encroaching on what we call the art of medicine.  

Choosing Wisely is a 2012 initiative of the American Board of Internal Medicine Foundation to reduce unnecessary tests and treatments and to help physicians and patients make smart and effective choices to ensure high quality care.

The brand Choosing Wisely Canada, and their logos and trademarks, have been licensed for use in Canada by the University of Toronto since 2014. A team from the University of Toronto, the Canadian Medical Association, and St. Michael’s Hospital (Toronto) is partnering with professional societies and clinical specialties to come up with lists of “things clinicians and patients should question.” In reality, however, some of these lists are admonitions: “Don’t do this,” and “Don’t do that.”

In Canada, for family practitioners the items on the list currently include:
•    Don’t do imaging for lower-back pain unless red flags are present.
•    Don’t order screening chest X-rays and ECG for asymptomatic or low-risk patients.
•    Don’t do annual physical exams on asymptomatic adults with no significant risk factors.
•    Don’t include screening digital rectal exams for prostate cancer or screening for testicular cancer.

Screening bimanual pelvic exams for ovarian cancer is also an item on the “don’t” list. I am not sure if annual pelvic exams are still on the Canadian “don’t” list: pelvic exams for well women were on the no-no list of the American College of Physicians but recently the American College of Obstetricians and Gynecologists reaffirmed that a pelvic exam should be performed on an annual basis in all patients aged 21 years and older. In British Columbia several of the examinations, laboratory tests, and investigations on the Choosing Wisely list are now off the fee schedule: a complete physical exam without a chief complaint may cost $150 or more.  

The good intention of Choosing Wisely Canada is laudable, and the “don’t do” recommendations are based on statistical and epidemiological outcome data collected by the organizers. Unfortunately, while such studies may be applicable to population groups, the conclusions fail to consider the uniqueness of each patient and the intricacies of the individual doctor-patient relationship. The “don’ts” are more directive than offering choices and do not offer alternatives.

For example, the “don’t do” admonition for bimanual pelvic exams or screening rectal exams for prostate cancer—the latter is on the “no” list ostensibly because family doctors do not know how to do it—could be resolved by pushing for appropriate training in the procedures.  

Given the Choosing Wisely Canada campaign, inspiring trust in the doctor during the patient’s visit will be essential when the doctor’s recommendation of certain investigations or treatment approaches are not in line with Choosing Wisely’s admonitions, or in line with what is on the list but contrary to the patient’s expectation.

Canadian Marshall McLuhan’s phrase, “the medium is the message,” is relevant here: the medium being the doctor’s behavior. Listening to the patient and doing the appropriate physical exam go a long way to affirming the doctor’s medical skills and diligence.  

I hope the day when the Choosing Wisely Canada logo has to be displayed on the door of a doctor’s office, or when a patient arrives with the Choosing Wisely “not to do” list in hand, is not here yet. 
—George Szasz, CM, MD

Further reading
Choosing Wisely Canada:

This posting has not been peer reviewed by the BCMJ Editorial Board.

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