Can We Choose Wisely?

Dr Ramai Santhirapala is an Honorary Consultant in Anaesthesia and Perioperative Medicine at Royal Surrey County Hospital and a Clinical Advisor at the Academy of Medical Royal Colleges. In the latter role she advises on the international programme ‘Choosing Wisely’, which aims to improve conversations between healthcare providers and patients. Dr Santhirapala’s specialist interests are shared decision making and end of life care, believing patients should lie at the heart of healthcare decisions. She has published in the British Journal of Anaesthesia and Perioperative Medicine and is undertaking research into educational needs for physicians to practice shared decision making. She tweets at @ramai23

choosing-wisely_2Shared decision making (SDM) is increasingly synonymous with healthcare, moving away from paternalism towards a balanced approach to decision making involving both patients and clinicians. What exactly is SDM? That is the ubiquitous question to which there is currently no universally agreed answer. The King’s Fund intimates a definition pointing out SDM is a process during which patients and physicians use evidence based information to support the deliberation process based on patients’ values, beliefs and preferences. This highlights that a physician is still expected to bring clinical expertise, whilst a patient brings expertise on what matters to them.

Current healthcare models are in times of challenge as we look towards solutions for long-term sustainability. Our population is changing and expanding, especially the over 85 age group, and comorbid disease is increasingly the rule rather than the exception. This is in the face of surging technical expertise meaning we can, when once we could not. However we should only when it aligns with patients’ values and preferences. No other time is there than now to deliver what Al Mulley, co-founder of the Informed Medical Decision Foundation, describes as ‘the care they need and no less, the care they want and no more’. Within the speciality of perioperative care, these may be decisions regarding specific technique of perioperative management, whether or not to go ahead with surgery and the level of appropriate organ support and end of life care. Underpinning high quality decisions are conversations which dig deep to understand what is important to the patient – this may be spending time with loved ones, walking the dog or as one patient said to me ‘watching the Great British Bake Off and Strictly Come Dancing every week in her own home’!

Recognising that better conversations lead to better decisions, in 2012 the American Board of Internal Medicine developed an international programme – ‘Choosing Wisely’ – specifically to encourage the dialogue between patients and providers. Seventeen countries followed suit, with the UK being the most recent launching in late October 2016. The UK programme is lead by the Academy of Medical Royal Colleges and had the aspiration to foster collaborative thinking across all the Royal Colleges and subspecialty faculties. We invited all the Royal Colleges and sub-speciality faculties represented by the AoMRC to consider five area of clinical practice where variation can be addressed through improved conversations. Twelve responded producing recommendations which were examined by the Choosing Wisely team of clinicians and policy makers alongside patient liaison representatives. We noticed variability amongst the royal colleges in the focus of recommendations. Some chose to identify five area of practice which we ‘should not’ do, for example a head CT in the event of minor head injury – simple and pragmatic. Others chose to challenge traditionally controversial, yet increasingly relevant, decisions broaching the topic of end of life care. The Royal College of Radiologists recommended reviewing the use of chemotherapy in advanced cancer where it is unlikely to be beneficial and the Faculty of Intensive Care Medicine recommend life support not to be offered where there is a high risk of death or severely impaired functional recovery. The Royal College of General Practitioners urged in those approaching end of life or frail, for a review of medications decreasing to only those which offer symptom relief.

We launched the first phase of Choosing Wisely UK on 24th October 2016 – this being a public-facing campaign with a website directed at patients and clinicians listing the recommendations alongside decision aids where available, professional guidance and patient education resources. It has been a steep learning curve; unique is a programme representing a cross-speciality professional collaboration promoted transparently in the public arena. It is challenging to know if the message of the need for better conversations will be clear and interpreted as intended. The response was beyond our expectations with the Choosing Wisely website receiving as many hits as a medium sized airline on the day of launch! Public, patients and professionals alike had much to say and we welcome the feedback. Clearly there seems an appetite for discussing healthcare decision making and the perceived barrier of ‘patients do not want it’ is simply not there.

On a personal level, or in the co-production of healthcare services, it appears people do want to take ownership of their healthcare. There were concerns over some recommendations, for example the recommendation to screen for PSA only when indicated by family history or race produced an emotive response especially from those who feels the PSA allowed for early detection of cancer. Perhaps surprisingly the end of life recommendations, which one may perceive as potentially emotive and controversial, have been received with enthusiasm – it seems the time is now to discuss death and dying. This is opportune as our profession opens its doors to this challenging yet mandatory conversation through organisations such as NHS England, NICE, the Faculty of Intensive Care Medicine and Intensive Care Society. In recognition that it is early days for Choosing Wisely, and much of the work lies ahead – changing culture is a slow burn far beyond the launch. Our next steps are to understand how we can embed these recommendations at the frontline – this takes money, strategy, many willing hands and patience. As it evolves, we hope Choosing Wisely represents a drop in the sea change towards patient-centred care.

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