This week lay and professional press will focus on a growing national collaborative of medical societies engaged in an information campaign for consumers. Choosing Wisely® wants patients and care providers to engage in discussion on the evidence for commonly used tests and procedures. Risk, harm and necessity are central to this conversation and a path forward for better understanding about commonly held beliefs.
Forks in the Road
This is not an easy path. In fact there are three forks in the road that make the journey to greater understanding a significant challenge. They are:
- Ritual and routine in clinical practice as well as general public knowledge
- Competing agendas within the industry, some tests and procedures generate revenue that will be hard to reign in
- Engaged patients is not yet a norm
Ritual and Routine
Years ago Muir Gray, one of the early leaders of evidence-based healthcare, pointed to this thorny issue as a driver of variation in healthcare. Changing habits and beliefs of clinicians is central to using best evidence as one guidepost for care. But the larger challenge is bringing the public into the conversation – using the science to engage people.
There is considerable variation in how studies are reported in media, making some seemingly simple decisions less so. For example, “Should I have a PSA test?” or “How frequently should I have pap test?” In the past we expected simple direction for our healthcare. Follow this routine screening and all will be well. Knowledge has moved us to a very different place where absolutes and one-size-fits- all is no longer safe.
Today individuals must engage in a shared decision-making with the clinician in order to understand the risk and benefit as it applies to their specific situation. This is a collaborative process, and it does take more time.
This same approach is necessary with treatment decisions. Think of the clinician facing a tired, anxious parent of a cranky three year old with runny nose, cough, and sore throat. “Why won’t you give me a prescription for antibiotics?” has a clear answer but when we’ve a couple of decades where antibiotics are freely given, even with viral infections, there is a national mind-set that must change. People can often feel they are not getting the “right thing” when this happens because it was so routine in the past.
So we are asking everyone to adapt, move forward in the conversation by using evidence. It is a work in progress but one aided by technology, specifically the smart phone. Gray describes this as the third revolution in healthcare driven by citizens, knowledge, and smart phones.
“In the nineteenth century health was transformed by clear, clean water. In the twenty first century health will be transformed by clean clear knowledge.” J. A. Muir Gray
If our first hurdle in transforming healthcare through knowledge begins with clinicians opening the door to meaningful discussions with patients, then how do we tackle competing agendas?
Every organization has its culture. Embedded in that culture are drivers and resisters to new ways of doing things. If you have ever-attempted policy and procedure change in a hospital you grasp the significance of competing agendas.
So when we consider the large picture the drivers of certain products, medications, and even information technology it’s essential to identify the desired outcomes first.
Know exactly what your practice setting wants to convey to your patients and minimize overload. Lay the foundation that will support measuring the results of your investment in time and money. Keep the goal of advancing the clear, clean knowledge to which Gray refers as central point.
Related Content: In the Forest of Safety and Engagement
Many folks are already on the engagement train, which is driving our industry forward. Only not fast enough to reach near Zero on HAIs and errors.
Let’s remind ourselves of one very important point here. Engaged patients or patient engagement has no common understanding. Although the term is touted by organizations and publications there is no meaningful definition, and there may never be one. But what is important is that within your own practice you arrive at a reference point for what this means to everyone who cares for patients in that area.
Without this base we simply add to the variations that have plagued our industry for the last several decades. As the Canadian researchers showed in a comprehensive review of the literature, there are multiple terms used to reflect this concept and many multiple definitions. This will be the focus of a future post.
This lack of understanding on what we hope to achieve in all the programs targeting the importance of informed consumers is perhaps our greatest challenge. Use of the many options that technology and the internet offer may be a clinician’s greatest opportunity to guide the best information into the mainstream.