Physicians must be advocates within their own practice, ensuring that appropriate investigations and management decisions are made with consideration, not complacency. Inappropriate ordering may lead to patient harm via anxiety and unnecessary further investigations. Both the clinical context and the “why” to justify the actions taken need to be at the forefront of a physician’s decision-making processes.
KEY WORDS: appropriateness, advocacy, clinical guidelines, Choosing Wisely
The phrase “physician advocacy” conjures many images: It could mean lobbying on behalf of one’s own patients to obtain a certain test, medication, or procedure; for fair compensation of physician colleagues; for comprehensive and team-based care; or for system changes to improve transitions and continuity of care for our patients. According to Isaacs,1 advocacy means, “stating clearly and confidently what one thinks and why one thinks it.” Top
For physicians, the word advocacy also brings to mind promotion of a concept to initiate a new project, to create improved policies and procedures — essentially, to do more. Yet, one of the healthiest ways we, as physician advocates, can contribute to the sustainability of the health care system is to consider just the opposite and proactively ask ourselves when can we do less? Top
There is an initial inner rebellion against the concept of physicians as “gatekeepers” of health care; we would do our patients a disservice by not ordering every possible investigation or intervention. Physicians are not economists or elected officials, and the Hippocratic Oath does not mention accountability for the public financial costs of what we recommend for our patients. Yet, although physicians must continue to staunchly advocate investigations or procedures a patient needs, evidence is mounting that much of what has traditionally been done or ordered in medicine is not in keeping with our holy grail of being “evidence-based.”2,3 In fact, sometimes just the opposite is true: some of what we do and order may, in fact, be inadvertently harming our patients.3 Top
One of the best lessons provided by some of my preceptors during my training was the habit of challenging the notion of automatic ordering. They would ask why I was doing or ordering something and how that would change my advice or treatment. Although vexing at the time, and equaling frustrating to my learners when I ask those same questions today, it has become an invaluable check on why I order or prescribe something. I admit that my hand is still tempted to order a urinalysis or ECG for an otherwise healthy elderly patient, a mammogram for a 40 year old woman, transaminases for patients on statins, or do a digital rectal exam of a 50 year old man. Asking myself “why” each time and the presence of students, to whom I am trying to teach the same habits, (usually) stays my hand. Top
There is increasing evidence that this non-evidence based ordering may be not only financially costly and noncontributory to improvements in patient morbidity and mortality, but, worse, it may also cause harm to our patients by leading to unnecessary anxiety and potential complications from resulting investigations or interventions.4,5 So, why is it that we continue to do and order what the evidence tells us we should not?
I suggest there are multiple reasons. First, it is difficult to change behaviour. What we were taught and have practised for years or decades is difficult to challenge and unlearn. Yet, as we tell our patients that change is possible, we cannot remain in a pre-contemplative stage.Top
Second, evidence-based clinical practice guidelines for groups of patients are cold, abstract words on paper or on a computer screen, disconnected from the concrete patient in front of us. All physicians have seen or heard about the “exception to the rule,” and these anecdotes carry emotional weight that can easily trump a scientific guideline.6
Third, it takes more time to explain why one is not ordering or doing something, than to create a requisition or make a referral. This is compounded by the way we have conditioned our patients to expect certain things, which, for example, explains the sceptical looks I receive when I explain that a clinical examination is not recommended for an asymptomatic patient at low risk for breast cancer. The Cleveland Clinic has been successful in influencing such expectations and patient experiences.7,8 Top
Fourth, one has to actively and continually seek out updated guidelines and re-assess “routine ordering.” Add to this the fact that it is easier to get groups of physicians to agree on ordering additional investigations than to agree on removing not-indicated tests. A physician making a referral may also worry that his or her patient will not be seen or receive the required investigation or procedure if all the pre-work requested by the consultant has not been done, even if it is not in keeping with guidelines.
Finally, it is challenging when the guidelines do not agree and one is inundated with a plethora of contradictory recommendations. Whether the disagreements occur between specialty groups or associations, or whether the differences are at a provincial, national, or international level, the fact remains that there is no single source of truth for everything when it comes to guidelines. Top
With all of these challenges and obstacles, how can we, as physicians, advocate health care sustainability and appropriateness in ordering investigations and interventions? As individual physicians, we need to continue to push ourselves to ask those “why” and “how does this change my management” type of questions. We need to stay updated on current and changing guidelines and use resources such as Choosing Wisely Canada9 and provincial and national screening guidelines, drawing from the expertise of physician colleagues who have weighed the evidence and provided guidelines that promote health rather than cause harm. Top
As a profession, we need to promote the dissemination of best practices through clinical guidelines readily available via electronic medical records and improved data sharing and integration. We need to measure whether what we do is achieving what is intended, rather than create unintended issues. Finally, appropriate ordering of investigations and treatments is a huge issue and will become even more so as governments seek to control health care costs, while we, as physicians, seek to continue honouring our traditional dictum: “first, do no harm.” Top
1.Isaacs W. Dialogue. New York: Currency Doubleday; 1999. p. 188.
2.Rosenberg A, Agiro A, Gotlieb M, Barron J, Brady P, Liu Y, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med 2015;175(12):1913-20.
3.Detsky J, Zlotnik Shaul R. Incentives to increase patient satisfaction: are we doing more harm than good? CMAJ 2013;185(14):1199-200. http://tinyurl.com/glptgaw
4.de Boer MJ, van der Wall EE. Choosing wisely or beyond the guidelines. Neth Heart J 2013;21(1):1-2. http://tinyurl.com/hmmrfjr
5.Fenton J, Jerant A, Bertakis K, Franks P. The cost of satisfaction. Arch Intern Med 2012;172(5):405-11.
6.Shermer M. The believing brain. New York: Times Books; 2011.
7.Merlino J. Service fanatics: how to build superior patient experience the Cleveland Clinic way. New York: McGraw-Hill; 2015.
8.Merlino J, Raman A. Health care’s service fanatics: how the Cleveland Clinic leaped to the top of the patient-satisfaction surveys. Harv Bus Rev 2013;91(5):108-16.
9.Choosing Wisely Canada, 2015. Available: http://tinyurl.com/jmz5dua (accessed 2016 Jan. 15).
Kathryn Andrusky, BSc, MD, CCFP, is a family physician at the Links Clinic in Edmonton, Alberta. She holds a number of leadership positions within the Alberta Medical Association and is particularly active in the areas of patient advocacy and primary care system reform.
Correspondence to: email@example.com
This article has been reviewed by a panel of physician leaders.