1. Workshop
Choosing Wisely

2. Learning outcomes Understanding stewardship of NHS resources
How to rationalise investigations
Communication with patients and the concept of shared decision making
Introduction to the Choosing Wisely campaign

3. When making a decision about choosing an investigation, what factors do you consider?
Can I deal with this result?, Do I know what this result means?, Is there a cheaper alternative? Will I be able to adequately store/ send on the specimen correctly?

4. Case
80 year old male with severe COPD on long term oxygen therapy was admitted to hospital with an infective exacerbation of COPD. His admission chest X-ray showed a mass in the RUZ and abnormal R hilum. What would be your next steps?
Book CT CAP and EBUS
Treat IE COPD and discharge with f/u with GP
Ensure adjusted calcium and LFTs are normal and book f/u CXR in 6/52
Liaise with respiratory about EBUS or CT guided lymph node biopsy
Discuss with patient all the above options and be guided by their decision

5. http://buzz. bournemouth. ac
[Accessed 09/07/2018]

6. Choosing Wisely UK Aim to reduce unnecessary interventions
Promote shared-decision making conversations between doctors and patients, to choose care that
is supported by evidence
not duplicative
free from harm
truly necessary
consistent with patients’ values

7. What is shared decision making?
Shared decision making (SDM) ensures that individuals are supported to make decisions that are right for them.  It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment.

8. 4 questions patients should feel free to ask their clinicians
The choosing Wisely Campaign has developed posters that can be displayed in waiting rooms to promote this approach

9. A case to reflect on……. 35 yr old female
Presented with fatigue & muscle aches to GP
+ve ANA
GP now concerned about lupus
Referred to rheumatology
Patient Googled lupus
Lots of additional vague symptoms which they associate with lupus
Seen in rheumatology clinic - very anxious
History and examination consistent with fibromyalgia

10. Implications Patient Anxiety
Time spent at appointments, having additional tests
Correct diagnosis + treatment delayed
Difficulty accepting that lupus is not the cause
Possible request for second opinions

11. Implications NHS Venepuncture Transporting sample to laboratory
Lab cost
Administrative time checking result and writing referral
OPA +/- further opinions
Clinician frustration

12. The scale of the problem
1/20 people have +ve ANA
3/20 people have musculoskeletal pain
1/2000 have SLE
For every patient with SLE there are 15 people with +ve ANA and pain
St George’s
Population ~ 1.3 million
~ 600 patients with SLE
> 600 ANAs every week

13. ANA + ENAs Antibodies do not equate to a diagnosis of a CTD
Avoid testing in widespread pain or fatigue alone
Only request tests if the implications are fully understood
Antibody picture unlikely to change

14. ANA + ENAs
Clinician:
Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.
No patient recommendation as felt to be too technical, but highest on working group’s recommendation

15. Over to you!
In groups please identify your top 3 key points which relate to your practice as a foundation doctor
You can use the ChoosingWisely UK website or Canadian or US websites
You will present these back to the rest of the group
You have 15mins!

16. Choosing wisely topics
Rheumatology
Radiology
Pathology
Emergency Medicine
Gastroenterology
General medicine- physicians

17. Time to present your findings

18. Canadian Federation of medical students
Don’t suggest ordering the most invasive test or treatment before considering other less invasive options.
Don’t suggest a test, treatment, or procedure that will not change the patient’s clinical course.
Don’t miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary

19. Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe are unnecessary.
Don’t suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.
Don’t suggest ordering tests or treatments preemptively for the sole purpose of anticipating what your supervisor would want

20. How do we put this into action?
Have you experienced people ordering unnecessary tests?
QIP projects
Plan, Do, Study,  Act.
Audits

21. Questions and summary
Thank you