Doctors to list iffy tests, procedures
CMA aims to cut health-care risks, costs
CALGARY Canada’s doctors will begin compiling lists of questionable or worthless tests and procedures that offer little benefit, and possible harm, in a move some doctors say could lead to a “sea change” in patient care.
At the annual general meeting of the Canadian Medical Association) in Calgary on Tuesday, delegates voted overwhelmingly to strike a working group to come up with a list of tests, interventions and procedures in every specialty of medicine “for which benefits have generally not been shown to exceed the risks.”
The move is modelled after the Choosing Wisely campaign in the U.S., an initiative launched in 2011 by the American Board of Internal Medicine Foundation and now supported by 50 medical societies that has identified nearly 100 procedures of dubious benefit, including X-rays, MRIs or CT scans for lower back pain and colonoscopies more than once every five or 10 years for average-risk patients. Colonoscopies can detect cancers of the colon and rectum. But they can also cause heavy bleeding, tears in the colon, inflammation and infection, complications that, in rare cases, can lead to blood transfusions, surgery or, rarely, death.
“Yes, it will be resource intensive. It will be worth it. The implications of this could be a sea change,” Dr. Geoffrey Blair, from the Canadian Association of Paediatric Surgeons, told doctors Tuesday. “This will represent good medicine, hopefully practised by good doctors, and will actually save money and ensure the sustainability of our health-care system.”
Studies suggest the overuse of tests and treatments accounts for up to 30 per cent of health spending, said Dr. Wendy Levinson, Sir John and Lady Eaton professor and chair of the department of medicine at the University of Toronto. Levinson worked on the U.S. Choosing Wisely campaign and is spearheading a similar version for Ontario.
“The whole goal of this is that it is physician-led — it is not government-led, it is not payer-led,” Levinson told delegates. “It is a very different message if physicians themselves say, ‘We think there’s evidence that these tests may be unnecessary.’ … The public trusts physicians and believes the credibility they bring to the table on this.”
The goal is to identify tests and procedures that pose risks, are often a waste of money and do not help patients get better faster.
‘This will represent good medicine … and will actually save money and ensure the sustainability of our health-care system.’
DR. GEOFFREY BLAIR Canadian Association of Paediatric Surgeons
In addition to X-rays for simple back pain or multiple colonoscopies, the U.S. lists include bone density tests for youth that can lead to people being treated for only mild bone loss with drugs that can cause chest or throat pain, problems swallowing and other risks; electrocardiograms for people at low risk of heart disease; and CT scans for headaches, when all that is often needed is a careful medical history and neurological exam to test things such as reflexes. A CT scan of the head can deliver a radiation dose that’s the equivalent of up to 300 X-rays, according to the Choosing Wisely campaign.
CT scans of the lower back can expose testicles and ovaries to radiation. Most back pain gets better on its own, but “red flag” signs that a CT scan may be needed include a history of cancer, unexplained weight loss, or loss of feelings or muscle strength in the legs.
Delegates on Tuesday also called for a national strategy for physician workforce planning to ensure the right number and mix of doctors is deployed across the nation. The last national review was completed in 1975, almost 40 years ago, Reid said.
Medical school enrolment has increased by roughly 80 per cent over its low point in 1997. But medical schools are training too many residents in some areas and too few in others. For example, Ontario expects to have 453 more general internal medicine specialists than it needs by 2021 — as well as an oversupply of orthopedic surgeons — but a shortage of 248 psychiatrists.
“Some provinces and regions are very good about making sure where the residents need to go — which residency programs need to be expanded and which need to be drawn down. But there is really no strategy across the country,” said Dr. Jesse Pasternak, a fifth-year surgical resident at Hamilton’s McMaster University and chair of the physician resource committee at the CMA.