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Skip to 0 minutes and 14 seconds What is Choosing Wisely? So Choosing Wisely is an international initiative. It’s really focusing on how to improve conversations between patients and providers. It started off in America in 2012 under the auspices of the American Board of Internal Medicine, in collaboration with Consumer Reports. And since then, it’s spread widely. So now there’s 20 countries involved in the initiative, of which the UK’s one of the most recent to launch– launching in October of last year.

Skip to 0 minutes and 47 seconds Why is Choosing Wisely needed? I think Choosing Wisely was needed, because it was partly a response to growing awareness of variations in practise–

Skip to 1 minute and 2 seconds that some medical care was not as evidence-based as it might be.

Skip to 1 minute and 8 seconds There was over-use of some tests and treatments. And that there needed to be a recognition of this. And the best way to tackle these problems is to encourage clinicians themselves to look at their own practise critically and do something about it in partnership with patients. Can you describe what Choosing Wisely involves? I think the thing that struck me going to an international Choosing Wisely meeting recently was that everyone’s doing it their own way in response to the needs and the contexts that they’re working in. So, I think there has been a certain development of ideas since it was first moved to, which was before its launch.

Skip to 1 minute and 55 seconds There was a paper in the BMJ, which I contributed to, which was about equal between the description of other models, which are about discouraging low-value procedures and practises. And then, the second half was about how to share those decisions with patients. And that’s a slightly uneasy fix, because what we’re trying to do is produce more effective medical care by discouraging certain types of practise, whereas shared decision-making is about giving patients a free choice between options. Which may or may not be ones that we particularly agree with. But that should always be done on the basis of good information about the effects of those practises. So, the hope I had for Choosing Wisely, was that it would move to shared decision-making.

Skip to 3 minutes and 2 seconds And in the process of explaining to patients the benefits and the disadvantages of treatment, patients might want less. But patients would choose, and we would simply observe that process and encourage that to be evidence-based. What advice would you give to a clinician wanting to practice Choosing Wisely? One of the first things we do is to promote the idea that it’s good to ask questions. So, encourage the patient to ask questions. Because the whole idea is the better conversations rest on two sources of expertise. So, the clinician has their knowledge about the condition, the diagnosis, the prognosis, etc. That’s the clinician’s knowledge.

Skip to 3 minutes and 48 seconds But to make a good decision, you really need also to understand the patient’s perspective on this– patient’s values, preferences, what’s important to them. And indeed then, what it is like to live with the condition and their particular social situation. So, the first thing to do is to encourage the patient to talk, and to listen to what the patient has to say, and then to present information about the options. And many patients need to understand that there are options, that there isn’t– there often isn’t just one way to treat a problem. And sometimes, the no treatment option is a good one that they should consider. So then, presenting the options, presenting risks, both the benefits and harms of the different options.

Skip to 4 minutes and 40 seconds And that needs to be done very carefully, because you’re often talking to people who will have no background in understanding probabilities and so on. Often graphics help, And so we talk about patient decisions aids. These are ways of summarising the information that patients need to understand if they’re considering having a condition, summarising it in very clear ways that they can understand. So, that needs to be tested carefully with patients. But making use of those– making use of those tools in the discussion, then checking that people have understood what their options are, and what the likely outcome of those options are, and then encouraging them to express their own views and preferences– What’s important to you?

Skip to 5 minutes and 36 seconds Which of these options looks like the one we ought to really discuss further, and think about whether it would help their problem? How are you engaging patients with Choosing Wisely? I think that’s the question we’re most wrestling with at the moment. We’ve tried to involve patients right from the start. All of the colleges have patient input of some kind. It’s really that continuous problem that you have that nobody wants to be a generic patient. Most of us would rather not see doctors, if we can help it. If we do see a doctor, it’s about something that’s pressing and anxiety-provoking, and that’s affecting us personally. So, I think this is something– this is work in progress.

Skip to 6 minutes and 27 seconds We’ve been discussing it all this morning, for instance. There are many patient groups that we can involve. I think we have to do it on a case by case basis almost. If there is a particular aspect of care that we want to discuss, we often want to discourage. We have to realise that patients often don’t understand why we should be discouraging something that seems an obvious benefit to them, like trimming a torn meniscus or opening a coronary artery when they’ve got Angina. It requires a fair amount of deep understanding of the issues. I don’t think we’re anywhere near the stage of public involvement in health knowledge. We don’t have the right knowledge environment to do this easily.

Skip to 7 minutes and 24 seconds But I do think that we need to explore the easy win situations, which are there. And there are many patients who do want to get involved in processes like this. The other thing is, we have to understand that we’re just one body among many who are trying to do this kind of work, and get across to patients that this is not about rationing. It’s about effective care. And it’s about non-burdensome care in many ways, for patients to have less done. And it’s for us, also, to show appreciation and listening to the counter-view that patients may bring. I think trust-building is the work of years, and possibly decades.

Skip to 8 minutes and 18 seconds But I think all of us are committed to that, which is why we’re sticking with it. How would you like shared decision making and Choosing Wisely to develop in the future? The benefits hopefully will be multi-various. There’ll be several benefits. One is that patients who understand better their health care, who are more aware of the limitations of medical care, and the risks, and the side-effects, as well as the benefits, who are, therefore, able to make better choices. And that should lead to a greater sense of empowerment, a sense of control over one’s own health. For clinicians who work in this way say that this is actually a much more satisfying way of working.

Skip to 9 minutes and 1 second So, instead of the doctor being put on a pedestal and expected to know all the answers and make all the decisions, this is a much more sharing approach, which is more satisfying for the clinicians, as well as for the patients.

Skip to 9 minutes and 16 seconds It may well lead to a reduction in unwarranted variations. Variations that are happening because there are beds that need to be filled, or because of fashion in medical care, and so on, to a much more evidence-based approach. And I think that’s key, actually. Evidence is at the heart of this. It is about sharing knowledge of the evidence on what works, and what doesn’t work with patients, and having a grownup discussion between two people who both need to understand each other’s perspective.

Skip to 9 minutes and 53 seconds I’d like to see some good examples of it happening in a way that has a tangible grip on patients and clinicians, so that they can see that it can be done, that it’s good, that it enriches the knowledge of both parties, that it encourages professional satisfaction. Hopefully, it also encourages patient satisfaction at the end of the day. From the patient’s perspective. I’m a patient, I’m not a clinician. From the patient’s perspective, it should be– it should make a huge difference, if the kind of culture change that I think we’ve been talking about, really happens. It means us being treated as grownups, quite capable of absorbing information if it’s well put across, quite capable of making decisions.

Skip to 10 minutes and 45 seconds Are we expecting to be involved in decisions, rather than having them made for us? Which after all, in all other aspects of our lives, we’re expected to do. So, it would be a much much more person-centered approach than we often experience nowadays. And I think I’d like shared decision-making to be as mainstream as evidence-based medicine is now. So, I’d like to see a time, certainly in our clinical career, where actually we’re not talking much of decision-making anymore, because actually that is the way practise.

Choosing Wisely

In this video interview, we are joined by Dr Angela Coulter and Dr Ramai Santhirapala who are the Chair and Clinical Lead respectively for the shared decision making subgroup of Choosing Wisely UK. Alongside this we are joined by Dr Richard Lehman who is looking to establish a unit focused on the shared understanding of medicine.

Choosing Wisely is an international initiative focused on improving conversations between healthcare providers and patients to ensure appropriate and patient centred and value based care. The combination of increasing innovation and a changing epidemiology of patients in times of constraint, means it is increasingly pertinent to match the right patient to the right procedure, and the time is ripe for an initiative such as this.

Choosing Wisely originated in the USA as a joint collaborative between the American Board of Internal Medicine and Consumer Reports.

It is professionally-led and public-facing, asking clinicians from specialist societies to work collaboratively with patients to identify five areas of practice where conversations could be improved.

Since the original launch in 2012, twenty countries have joined the initiative with the UK being one of the most recently in late 2016 under the leadership of the Academy of Medical Royal Colleges.

The Academy of Medical Royal Colleges (AoMRC) governs all the medical royal colleges and speciality faculties in the UK as well as providing a conduit for frontline clinical staff to the wider NHS, Parliament and the Department of Health. It is also often called upon by British and International media to provide statements on behalf of the professional body. This places the AoMRC in an ideal position to lead Choosing Wisely UK.

Ahead of the launch of the UK arm, the AoMRC asked its representative Royal Colleges to identify areas of practice where conversations could be improved reflecting the original US initiative. Responsive to the lessons learnt from the international initiative, Choosing Wisely UK has an early focus on shared decision making as the vehicle for better healthcare conversations. Specifically this will be through supporting education and training strategies as well as developing a tool kit for local implementation.

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Perioperative Medicine in Action

UCL (University College London)