‘Choose wisely’ movement pushes for more selective testing in Nova Scotia health care

Dr. Sam Campbell, chief of emergency at the Halifax Infirmary, says doctors must put the medical need for the test before emotional considerations such as placating their patients. The supposed first rule of medicine (it’s actually not in the Hippocratic oath ) is first, do no harm.

But doctors are humans and when your mission is to fix people, the more realistic credo might be summed up as, do something.

“Prescribing antibiotics and ordering tests is more an emotional reaction,” said Dr. Sam Campbell, chief of emergency medicine at Halifax Infirmary, in a recent interview.

“Emotion beats logic, it makes us feel good, it makes us feel like we’re giving the patient something. When someone waits in the waiting room for several hours and they see me and I shrug and say, ‘Well there’s nothing I can do for you,’ as opposed to, ‘Well, I can give them something.’”

While Campbell is quick to note that medical technology is “fantastic, we’re way better at diagnosing and managing disease with modern tests then we were before,” there is growing concern about the consequences of the testing culture.

Campbell pointed to a study released this week co-authored by Calgary pathologist Christopher Naugler for the C.D. Howe Institute. It concludes that up to 30 per cent of tests, procedures and treatments associated with eight common medical tests are potentially unnecessary.

The study confirms what Campbell and other doctors involved in the Choosing Wisely campaign, which urges doctors and patients to talk about whether a test is actually necessary, have been saying for years.

While the C.D. Howe’s spin on the study emphasized the billions that are wasted in unneeded testing, Choosing Wisely proponents are more concerned about the potential harm.

“If I do 20 tests on you, just as a statistical phenomena, one of them’s going to be abnormal,” Campbell said.

“The trouble is, we’re not very good at ignoring abnormal results. So then you have another test, which leads to another test, which leads to another test. And this is what they call Ulysses syndrome, which is a kind of medical adventure where you go and have all these things where you hopefully eventually end up getting better — although occasionally people have unnecessary operations, there’s a lot of unnecessary stuff that goes on.”

The final fall at the end of all those testing dominoes can be catastrophic. Campbell referred to a case of a woman, identified only as Fran, whose eventually fatal testing journey began with a seemingly innocuous piece of advice from her doctor that she lose weight in order to combat higher than normal blood pressure.

Fran lost so much weight that the doctor feared something else was going on so he ordered tests that indicated a pancreatic growth.

That test result eventually was found to be a false positive but in the meantime, she had exploratory surgery, after which she developed a urinary infection. She was prescribed an antibiotic for the infection, which conflicted with a blood thinner she was on, and Fran ended up dying from a massive gastrointestinal bleed.

While that’s on the extreme end of the potential consequences of over-testing, Campbell listed off a series of examples of the negative impact on patients’ lives, from the huge problem of unnecessary prescriptions of antibiotics for things like colds to X-rays for back pain that reveal arthritis.

Arthritis of the back is a common effect of ageing but “when I tell you you’ve got arthritis, I’ve turned you into somebody who’s basically healthy and has got a bit of back pain to somebody who’s got arthritis. You see yourself differently.”

While even marginal improvements in reducing unnecessary tests will improve many lives, the long-term solution must include a fundamental change in the relationship between doctors and patients, Campbell said.

“We need a culture change. We have to change our culture to one where we question whether we need tests as opposed to blind belief that a test will help just because it’s a test.”

Campbell and Dr. Constance LeBlanc will lead a discussion on this issue April 8 at the Halifax Central Library beginning at 6:30 p.m.

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