1 Critical thinking in Family MedicineWelcome to Family Medicine. Drs. Carolyn Nowry and Jillian Ratti NW Division R2s May 25, 2017
2 Welcome to a career in Family Medicine/ General Practice!Exciting transition from residency to practice! Deep breathe – exams are over – time to start looking ahead
3 What are your plans? Further training Go into practice?Advanced skills? Go into practice? Where: rural/urban/suburban? Generalist practice or Focused? Locums? No idea? It’s ok!! Go around to group; get a sense of what future plans are
4 Economic concerns: difficult to find positions.Pictures from Go where needed: Canada’s third world.
5 Low gratitude “The greatest generals never have glorious victories in battles” Sun Tze, The Art of War Prevention, asthma, diabetes, etc Low glamour Best general never gets into battle – link to prevention
6 Objectives Review previous sessions, check for questionsThe process of diagnosis The inevitability of error in medicine, How to handle it Reflect on how to keep up to date in practice Referrals and relationships with specialists
7 Respiratory treatmentsHave you prescribed antibiotics when they were not indicated? How do you talk to patient’s about the harms of antibiotic use? Which OTC products do you recommend to patients? Have you checked out what is available at the pharmacy?
8 Anticipatory GuidanceCough duration: Systematic review – mean duration of cough = 17.8 days ( ) Studies using the bronchitis severity score found most episodes lasted >2wk Patient Survey – mean estimated duration of cough = days Implications for antibiotic prescribing? Ebell, Mark et al. How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature Ann Fam Med 2013;11:5-13. doi: /afm.1430.
9 “Leave it alone and it will get better.”Exceptions; safety netting Identify when it is getting worse and something needs to be done. Don’t forget to document discharge instructions!
10 Preventative Health
11 Health Equity and the Social Determinants of Health, Recognize that what we do as doctors is minimal by comparison with social conditions and behaviors Health Equity and the Social Determinants of Health, Canadian Medical Association 2012.
12 Our role as advocates Add in upstream -
13 Balance of benefits vs harms
14 Investment of resourcesDifference between benefit and harm Benefit Main point – find net benefit Benefit vs harms at patient level Stewardship of resources Optimality - Net Benefit Harm Investment of resources Fig. 4 The relationship between the beneficial and adverse effects of screening- after a certain level of investment, the health gain may start to decline.
15 Presentation of Harms Guidelines do not tell us much about harmsPhysicians do not like to think about harms We do not measure them Trial publications do not require them So reviews/guidelines cannot include them Physicians do not notice and recall them Poorly measured: not on the radar Arguments: we do it better here, so not our problem. Reflect on each bullet point
16 What are the harms? Poorly measured: not on the radarArguments: we do it better here, so not our problem. Talking about paps
17 Harm: pelvic exam Pelvic exam: no benefit foundPurported to find ovarian and uterine cancer Both are diseases of women >40yrs. No evidence that screening works: Uterine: causes bleeding before increased bulk Ovarian: screening trial with ultrasound reduces mortality minimally (many false positives)
18 Don’t do routine pelvic exams!Check in regarding difference in preceptor practices – keeping up to date Locums? Patient expectations? The most unpleasant component. Sawaya, George. Screening Pelvic Examinations: The Emperor’s New Clothes, Now in 3 Sizes? doi: /jamainternmed
19 What are the harms? Labelling abnormalProcess of diagnosis: colposcopy & biopsy Discomfort, bleeding and discharge Poorly measured: not on the radar Arguments: we do it better here, so not our problem.
20 Number referred for colposcopyColposcopy Referrals by Age Group in Alberta Cervical Cancer Screening Program (ACCSP) Age group (Years) Number screened Number referred for colposcopy % referred 24,985 497 2.0% 194,499 10655 5.5% 210,833 7671 3.6% 173,359 3624 2.1% 154,986 2412 1.6% 80,344 806 1.0% >= 70 13,705 166 1.2% Total 852,711 25831 3.0% High in youngest group
21 >21yrs: ~20% reduction in frequency of testing.Changes in Pap tests by age: Calgary area SA Sayed, C Naugler, J Dickinson. Work in progress Can we get to zero? What is the root cause? How will you prevent yourself from being group of doctors who are behind the curve? >21yrs: ~20% reduction in frequency of testing. No change in 2013
22 What are the harms? Labeling abnormalProcess of diagnosis: colposcopy & biopsy Discomfort, bleeding and discharge Treatment: LEEP More bleeding and discharge Cervical incompetence 1.2% ⬆️ Early Preg Loss Premature labour: NICU etc Poorly measured: not on the radar Arguments: we do it better here, so not our problem. Anxiety Affect young, pre-family>> those with completed family 5. Difficult to get insurance
23 Complications of treatmentDecision balance Benefits Harms Anxiety Over-diagnosis Complications of treatment Reduced morbidity Reduced Risk of death
24 Objectives Review previous sessions, check for questionsThe process of diagnosis The inevitability of error in medicine, How to handle it Reflect on how to keep up to date in practice Referrals and relationships with specialists
25 Difficulty in diagnosisPaul Glasziou MBBS FRACGP PhD Formerly Professor of Evidence-Based Medicine, Oxford Director Centre for Research in Evidence-Based Practice Bond University, Queensland https://www.youtube.com/watch?v=xqXSzlVRH6E Talks about challenges as a young MD with diagnosis, did a PhD in it – no help! Start: to-18:20 Then talks about overdiagnosis
26 Medical error Tasks of Family Medicine Diagnosis InvestigationManagement Referral Integration Prevention Communication I have made errors in every component.
27 Recent errors One CN case and one JR case
28 Your errors? Tell your neighbour about itAnyone feel comfortable sharing? Could all learn from? 1 or 2
29 Types of diagnostic errorNo Fault Unusual presentations, patient’s withhold info “Necessary fallibility” System Errors Due to limitations of the health care system; technical or organizations issues Cognitive Errors Tend to be minimized Often due to biases, perceptual errors “Cognitive dispositions to respond” Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003: 78:
30 Common causes of Diagnostic ErrorsAnchoring: lock onto features in presentation to early; +/- confirmation bias Availability: affected by recent experiences Diagnosis momentum: labels stick to patient Omission and commission bias: tendency towards inaction/action Premature closure: accepting a diagnosis before you have all the information Sunk Costs: personal investment in particular diagnosis Visceral bias: ie. Countertransference – both positive and negative feelings towards a patient. Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003: 78:
31 How to reduce diagnostic errors?Force yourself to consider alternative possibilities “What else could this be?” Metacognition “Thinking about thinking” Decrease reliance on memory Clinical decision aids, DDx tools Feedback Follow up!! Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003: 78:
32 How do we cope with bad outcomes?Was there an error? Could things have been different? Disclosing unanticipated medical outcomes Significant Event Audits Be aware of risk of IGBO = I Got Bitten Once Bad outcome does not necessarily = error CMPA - encourages member physicians to disclose to patients the occurrence and nature of adverse outcomes as soon as is reasonable to do so after their occurrence. IGBO error
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34 Knowledge is necessary But it is not sufficientMust set that knowledge into clinical and mental pathways so it is usable.
35 Seeking Perfection The “good enough” parent: DB WinnicottJanet R. Gilsdorf, The Good-Enough Parent JAMA. 2016;316(20):2089. doi: /jama “Good enough” doctors Cannot seek perfection Probability game: balance of harm vs benefit Winnicott – get away from trying to be perfect Bettleheim – also parenting Reflecting on parenting
36 Further reading Croskerry P. From mindless to mindful practice – cognitive bias and clinical decision making. NEJM 2013; 368;26, Smith AK, White DB, Arnold RM. Uncertainty – the other side of prognosis. NEJM 2013: 368;26., Reference on slides
37 Objectives Review previous sessions, check for questionsThe process of diagnosis The inevitability of error in medicine, How to handle it Reflect on how to keep up to date in practice Referrals and relationships with specialists Break?
38 Learning curve Long way to go! Learning Graduation CCFP Time
39 Charles Burwell Dean of Harvard 1935-1949"Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which." What do you think? It is wrong – Central concepts vs details Ie salbutamol vs MAB
40 How to keep up to date in practice?
41 How up to date should we be?How fast does information change? How reliable is new information? When should we start to use new drugs? Adding new drugs: likely to be biased: interest of companies and researchers to publish positive outcomes, in most favourable population groups. 1/3 of drugs will be pulled from the market Trials: focus on benefits, difficult to measure harms: often take longer to appear. Also dishonesty Harms of new drugs: react immediately.
42 Acquiring informationPull vs Push Reflecting on pushed info What are you using now in each category, how do you make sure that you will get practice changing info How do you know what you don’t know
43 Sources of InformationPoint of care, Journals, Guidelines, Databases Hunting vs Foraging How much bias? Topics chosen How the information is presented
44 Patient-Oriented Evidence that Matters Disease-Oriented EvidencePOEM vs DOE Patient-Oriented Evidence that Matters Disease-Oriented Evidence J Fam Pract Jan;49(1):63-7. Becoming an information master: using POEMs to change practice with confidence. Patient-Oriented Evidence that Matters. Slawson DC, Shaughnessy AF.
45 Outcomes Surrogate outcomes POEMLower LDL, reduced HbA1c, random biomarkers Changed Xray appearance POEM Mortality Disability Pain
46 “Hunting Tools” Dynamed* Uptodate Essential evidence Plus* Rx filesGuidelines – TOP, preventioninhand.ca, CPG Infobase TRIP Database MyStudies NNT.com Help with DDx: Isabel, DxLogic, SnapDx, Visual Dx Google? *available with CMA membership
47 Evaluating Hunting ToolsRelevance Patient oriented vs disease oriented outcomes Applicability to location of practice Validity: Are the strength of recommendations supported by clearly defined levels of evidence? How often is the information updated? What is the funding source? Other sources of bias? How much does it cost? Is is easy to access and use? Adapted from Centre for Information Matstery:
48 Unified place for quality informationIssues with guidelines
49 “Foraging Tools” Push POEMs (via CMA)E-therapeutics highlights (via CFPC) Tools for Practice (via ACFP/CFPC) UBC This Changed my Practice (free) Dynamed Plus (via CMA) Evidence plus (via McMaster) Prescriber’s Letter Podcasts (Best Science Medicine, AFP, PC Rap) TOP Guidelines PBSG Modules (and pull)
50 “Foraging Tools” Pull Journals Cochrane DatabaseGet the table of contents via or podcast! Caution with original research, focus on reviews by FPs CMA, CFP, AFP, BMJ JAMA: avoiding overdiagnosis series Cochrane Database
51 Evaluating Foraging ToolsWhat is the scope? Is is appropriate to your specialty? POEMs vs DOEs? Are the recommendations supported by clearly defined levels of evidence? Does it have criteria for what types of sources are used? Cost? Availability? Ease of use? Adapted from Centre for Information Matstery:
52 Social Media Blogs: YouTube TwitterJessica Otte: lessismoremedicine.com Jonathan Tomlinson: https://abetternhs.net/ Richard Lehman’s journal blog (via BMJ) Sara Taylor: saratmd.com (Physician wellness) Kevin MD YouTube Mike Evan’s videos TOP Twitter
53 Pharmaceutical dinners meetings free journals samplesWhat problems?
54 What do you think about it?
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56 No free lunch! Drug company tactics Pre-plan before approvalPublish positive articles Create compliant influencers KOL: Key Opinion Leaders Widen diagnostic criteria Find off-label uses Misleading advertising Samples? New guideline for old condition Challenge with Samples - ways to get
57 The Drug Game Set up Guideline Selling to profitable marketResearch focused on drug-treated diseases Distorted trials Wrong comparisons, selected results Stretch definitions HT, Diabetes, Cholesterol, osteoporosis, Depression, Dementia, Create new “disease” menopause, Low T Set up Guideline Ex-editors of NEJM Kassirer J. On the Take OUP 2005 Moynihan R, Cassels A. Selling Sickness: how drug companies are turning us all into patients. Allen and Unwin, Sydney, 2005 Angell, M The Truth About the Drug Companies.Random House NY 2004
58 Ben Goldacre Author of “Bad Science” and “Bad Pharma” https://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe TED – Ben Goldacre talk? https://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe ** change**
59 Drug reps During training, I was told, when you're out to dinner with a doctor, “The physician is eating with a friend. You are eating with a client.” Adriane Fugh-Berman , Shahram Ahari Following the Script: How Drug Reps Make Friends and Influence Doctors. , 2007 PLoS Medicine https://doi.org/ /journal.pmed https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/ What is common about all the drugs in the sample cupboard? High profit drugs Deciding if they will see drug reps; how to deal with
60 Objectives Review previous sessions, check for questionsThe process of diagnosis The inevitability of error in medicine, How to handle it Reflect on how to keep up to date in practice Referrals and relationships with specialists Relationships with specialists – blindly follow specialist recommendations
61 Class gradient and specialistssuper-specialists>general specialists city specialists> rural specialists any specialist> family physicians FPs: peasants of medicine Dutifully accept whatever our superiors say Do we accept this? Make decisions that patients need. We take responsibility for care of the patient Addressing the challenges Mentality of “lowly FP”
62 Eg. Lipids for primary preventionExample of differing perspectives between primary care and specialty care CCS Guidelines vs TOP Guidelines How to deal with? Vital importance of shared decision making We are generally MUCH better at this because we have longitudinal relationships with our patients!!!
63 Shared Decision MakingLearning to talk to patients about the evidence Need to assess knowledge, be clear about time frame and main endpoints, use absolute terms Avoid NNTs Use visuals!!!
64 Shared Decision Making - ResourcesAntibiotic prescribing: antibioticwise.ca, dobugsneeddrugs.org Canadian Preventative Task Force Mammography, PSA screening Mayo Clinic - shareddecisions.mayoclinic.org Best Science Medicine CVD Risk Calculator bestsciencemedicine.com/chd/calc2.html Afib and antiocoagulation - Optiongrid.org Choosing Wisely Canada Myhealthalberta.ca
65 CVD Risk Calculator
66 Bone Health Choice Decision Aid
67 CTFPHC: PSA Screening
68 Repeat prescriptions: WarningEvery repeat is a decision-point Is the disease: Improving, stable, getting worse? Need monitoring? Is the drug Appropriate? Causing side effects? Example: I just need some more T3s doc Depresicribing!!
69 De-prescribing!!
70 Reasons for referral Sick patient: needs hospital careManagement: specific technical Eg surgery, complex treatment. Diagnosis of problem Patient wants it Are we a steward of the system?
71 Functional definition of primary careProvides entry into system for all new needs and problems Provides person-focused (not disease-oriented) care over time Provides care for all but very uncommon or unusual conditions Coordinates or integrates care provided elsewhere by others Should be able to handle 95%+ of problems Fitting in to the system, our place is in health care – NPs, etc Disappointed to hear that a patient with renal failure on dialysis was told too complex for a teaching centre. Barbara Starfield
72 “Minimally Disruptive Medicine” Victor Montori minimallydisruptivemedicine.org https://www.youtube.com/watch?v=cHSWDMH2rfc Back to the Basics- focusing on the whole person Beware of harms of over-labelling “Pre-diabetes, pre-hypertension, pre-osteoporosis” “Minimally Disruptive Medicine (MDM) is a theory-based, patient-centered, and context-sensitive approach to care that focuses on achieving patient goals for life and health while imposing the smallest possible treatment burden on patients’ lives.”
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74 Examples: freidreich’s ataxia: developed hemolytic anemia.Severe SLE: gets pleuritis: peritoneal, pleural Common variable immune deficiency: needs infusions of IGG Specialists care, but they also get common problems, need preventive care Don’t look for Zebras But do check Zebras for their high risks AND treat for ordinary equine problems
75 “Failures” of Family Medicine23% of cancer diagnosed in ED! Conference – GPs doing ”terrible job” – are we?
76 Canadian Cancer Statistics 2016
77 Time course of disease Sudden onset Onset over few hours/daysSlow development over weeks Intermittent Slow development then catastrophic presentation Most developed in neurological disease Recongizing what we can change, loading on you Eg spinal crush fracture. Liver secondaries as presentation.
78 Failures of Family Medicine23% of cancer diagnosed in ED! 45% lifetime probabilty ASIR 500/100,000 per year Practice Population 1000: 5/year In 2 years: 1 prostate cancer, 1 breast, 1 colorectal, 1 lung, 1 all other cancers, all others less often. Tough job to find those
79 Failures of Family Medicine23% of cancer diagnosed in ED! 45% lifetime probabilty ASIR 500/100,000 per year Practice Population 2000: 10/year Cannot do early diagnosis of all “Risk sink” of health care system (D Haslam BMJ) Must take some risk, wait for disease to declare itself 1 prostate cancer, 1 breast, 1 colorectal, 1 lung, 1 all other cancers, all others less often. Accept that we are going to miss things
80 Why does Family Medicine need our own knowledge base?Different setting Different epidemiology Different probabilities: low prevalence Therefore always “screening” Separating important from self-limiting “Risk sink” of health care system (D Haslam BMJ) Different purpose Help people through their life We will always fail: early disease difficult to diagnose. 23% of cancer diagnosed in Emergency rooms. EG 70 year old man difficulty swallowing, weight loss 67 yr old woman back pain. Risk sink of health care system: like heat sink in computer (D Haslam) Never cure anyone!
81 Objectives Review previous sessions, check for questionsThe process of diagnosis The inevitability of error in medicine, How to handle it Reflect on how to keep up to date in practice Referrals and relationships with specialists
82 Questions? Comments? Objectives Share stories