9 Apr 2019
A healthy 50-year-old man and father of three was symptom free but proceeded with a PSA test. The results were slightly high, so he went for a biopsy. During the biopsy he got an infection which caused a stroke due to a septic embolus, and he lost function of his dominant arm. The biopsy was negative, but he now has a permanently paralysed right arm and hand.
This was one of the stories Dr Peter Kuling shared with the Commission when visiting recently to discuss over-diagnosis, over-screening and over-treatment. Dr Kuling is an assistant professor of family medicine with the University of Ottawa, Canada and has held numerous leadership positions. He delivers several quality improvement programs around the world and is a champion for Choosing Wisely Canada. He shared with us his Canadian perspective on the concept of risk-of-harm and shared decision making.
He says GPs go to work each day committed to providing the best possible care for their patients.
‘Sometimes they can feel pressure from patients to over-prescribe or over-investigate. We have developed tools that will guide the conversation between the patient and the doctor to discuss whether or not a test should be carried out. That’s shared decision making. We need to get physicians back into conversations with patients rather than the doctor “telling them what to do”.’
Dr Kuling says physicians can over-test because they fear missing something, but they shouldn’t practise out of fear but rather continue to practice evidence-based medicine.
‘We need to use the data that’s out there that shows risk-of-harm to inform our decisions.’
The very act of ordering tests, and finding results that aren’t actionable, can be problematic for the patient.
‘If you tell the patient there’s an area on an x-ray that’s suspicious (i.e. mammogram), and you need to investigate further with additional views, but eventually determine that everything is fine (a false positive), the patient often still thinks something may have been missed, and their anxiety level is significantly affected. There is evidence from psychological testing that false positives increase anxiety by 50 percent.’
His biggest concern is around imaging such as CT scans and MRIs.
‘Consider a patient who has sprained their knee but doesn’t need an x-ray. The patient wants to know what is wrong with their knee and it’s easy enough to order imaging, but the results won’t change the management of the injury. Dialogue is key, so patients have a chance to express their concerns, doctors can share the evidence, and both parties can decide together about what to do next.’
Dr Kuling shared a story of a friend he’s visiting in Wellington who wondered if he should have a full body MRI. ‘He said “Well I’m 70 now, I’m feeling pretty good but maybe I should have it”.’
‘I can guarantee that total body MRI will find a few things (false positives) – a little growth here and there that is highly unlikely to be significant. But those few incidental findings will cause increased anxiety and can easily cascade into a whole bunch of tests.’
In April 2017, the Canadian Institute for Health Information reported that Canadians undergo more than one million medical tests and treatments every year that they may not need.
‘If a 50 year old patient comes to see me and feels entirely well and there’s nothing to suggest any problems, I focus on prevention and lifestyle advice based on good evidence rather than doing a wide array of investigations. I can say come see me if you get sick rather than for a routine yearly medical. This means doctors can be available to see patients that are ill on the same or next day, rather than doing routine medical checkups which block the daily schedule and that evidence shows are unnecessary.’
The idea is to help family physicians shift their focus to supporting wellness, which hinges on the quality of communication with patients.
‘Better conversations build trust.’