I trained in South Africa. Now this is a country with the biggest gap between the rich and the poor in the world. I only learned of the true effects of societal inequality once I began my medical journey at age 18 when I entered medical school. The access to a family doctor I had growing up was excellent. He knew me and my family’s health issues throughout my formative years. He was able to treat my rather troublesome asthma with the latest drugs (inhaled corticosteroids) as soon as they were available-and finally I was able to live as a normal child and play all the sports I desired. As ‘previously advantaged’ white people, we had access to any medical service we required and did not think twice about it. This was all privately insured and not part of the public system I trained in when I began medical school. By stark contrast the public system had a paucity of available tests, treatments and drugs. How were we to care for our patients in this two-tier system? We were taught to take careful histories, conduct thorough clinical exams, weigh up the benefits of our clinical decisions based on good clinical medicine combined with evidence-based decisions – what now seems like a very old-fashioned approach (I completed my training in 2009). We simply could not be wasteful in our practice of medicine – we did not have the resources.
My experience in rural and urban Alberta since 2011, proved that despite having access to a host of health services including diagnostic imaging, any lab test at the drop of a hat and all the latest drugs, that Albertans were still not receiving high quality care they deserved. I suspected that many of them were being harmed more than they were being helped by tests, treatments and procedures being ordered at a dizzying pace. There is no better experience of this uneasy situation than practicing in a community where many of the population are unattached to a family physician. As folks floated between physicians providing intermittent care I witnessed a cascade of unnecessary testing, inappropriate prescriptions, of often very dangerous drugs, and a host of other head-scratching practices. When I observed this in my community I was honestly ashamed of our profession – how did this happen? We cannot simply blame our colleagues. When I took a step back I observed a complex status quo which combined entrenched patient expectations and desires, physician remuneration issues, a lack of comprehensive-care practitioners, and the influence of for-profit marketing of medical services and drugs.
After being disappointed by the state of clinical medicine in my community and the lack of patient-centered resources I had access to – I stumbled upon Choosing Wisely Canada which was beginning to take hold in Ontario. Now if we could get that going in Alberta we might have a shot at changing medical practice for the better I thought. This was in late 2014.
I began to travel to various medical conferences in Alberta and beyond and I was excited to discover that so many of my family practice colleagues were in a similar situation (in all types of practices) and frustrated. Was it difficult to convince fellow practitioners that we are currently on the wrong course? Not at all, they are observing the same problems!
Am I being ‘old-fashioned’ or too restrictive in my philosophy of clinical practice? Perhaps you think I am a cynic or a therapeutic nihilist – you are mistaken. The more we research the issues of overuse, over-diagnosis and harms within our system, the more we realize the enormity of the problem. Really what I am talking about is going back to the way we ought to live, as in life, as in medicine – less is more. At the core of Choosing Wisely is the recommendation that we lively sensibly and healthily in terms of exercise, diet and other common-sense suggestions.
We cannot wait for ‘the government’ to change things, we cannot wait for patients to demand change – the change in the way we practice and deliver medicine needs to come from frontline physicians. With your help, we are going to take back clinical medicine from forces that would have us distracted from changing the social determinants of health, we are going to lead the charge for change on behalf of those communities we serve. We are under a solemn social contract to do this work and we are not going to give up. Join me in Choosing Wisely for the sake of our patients.
Dr. Anthony D. Train MBChB CCFP is a family physician based in Calgary, AB. He is Alberta’s Primary Care leader for Choosing Wisely Canada. He is a board director at the Alberta College of Family Physicians. He practices comprehensive family & emergency medicine. He believes that in many cases ‘less is more’.