CHOOSING WISELY MANITOBA - Key Persons

Job Titles:

• Director, Health Services

Job Titles:

• Technical Director for Transfusion Medicine, Shared Health

I think Choosing Wisely matters to every patient I see as it refocuses me to think carefully when making treatment decisions. As a physician, I accepted the obligation stated in the Hippocratic Oath to "do no harm" and fundamentally I think that is what Choosing Wisely is about. If physicians provide unnecessary or extraneous care, we will eventually harm someone - no diagnostic test, procedure, or medical treatment is risk free. Not only do we need to know when to do provide certain potentially life-saving tests and treatments, but equally important is knowing when not to perform those same interventions if doing so might actually harm the patient given different circumstances. Importantly, the Choosing Wisely campaign doesn't try to tell us "never" do something, but rather encourages and supports us in using our clinical judgment and evidence-based patient centered rationale to make the best decisions. Typically medical education encourages us to be thorough, which is generally a good thing, but taken too far, we risk failing to be judicious when it is appropriate for our patients to do less. I appreciate Choosing Wisely Manitoba for keeping us on top of the evidence and challenging us to question what we do. I think it's useful that these recommendations are convenient, concise, peer-reviewed and evidence-based. In my practice, we've noticed that once you get engaged in thinking about the Choosing Wisely recommendations there is a collateral benefit - even if you haven't memorized all the specific recommendations, you find yourself naturally questioning and more likely to modify your clinical practice for the patient in front of you. It also gets us thinking about other quality and efficiency improvements in our clinic that may be more "lean" than "choosing wisely". One of the challenges or risks related to the advancement of the evidence-based medicine paradigm is that we seem to be encouraged to follow algorithmic protocols that can take discourage the heuristic interaction between patient and physician. Choosing Wisely encourages us to be judicious interpreters selecting the interventions that are right for our patients and being more cognizant of our role to treat each patient as an individual and not apply tests and treatments indiscriminately. Personally, I think it helps me be a more mindful doctor ensuring my care leads to truly beneficial outcomes in my patients.

Job Titles:

• Medical Director for Transfusion Medicine and Hematopathologist Shared Health Diagnostics, Assistant Professor University of Manitoba

Choosing Wisely is important for the sustainability of health services, not just for my patients, but for all Manitobans. We only have so many resources and I want to ensure we're allocating tax dollars to the highest value services my patients really need. I am a witness to this on a daily basis, appraising my actions while advocating for the best care for my patients; so I feel a duty to "Choose Wisely" so my patients will get the care they really need, now and into the future. Communication is critical in making this initiative a reality. Meeting the expectations of our patients needs to be managed in a socially accountable manner by educating and setting a behavioral standard at each clinical encounter. Any day that I can pass this information on to one of my patients is a good day in clinic. Any day that they can carry that sentiment forward to others is an even better day! Fortunately in my practice, I am starting to see patients who are becoming wise to unnecessary drugs and diagnostics. A great example is the work up for acute lower back pain. This is a great opportunity for a one on one discussion on the topic of unnecessary x-rays, CT's and MRI's. I will often ask my patients about their expectations of the outcomes of a specific test. If they request a CT scan, do they worry about the radiation exposure, are they concerned about their condition worsening, what do they think the harm is in delaying an exam, what red flag symptoms should they be aware of? It gets us to the heart of their expectations, and often we can agree that we don't need to do the test. We can then move onto a management plan, which gives a feeling of satisfaction. Communication is also moving forward between our medical experts. During our CPD sessions, conversations about social accountability are occurring more frequently. Scientific planning committees are now integrating Choose Wisely tools at many of our educational events and physicians, both new and established, are utilizing these resources that will help support them in their daily clinical encounters. Unfortunately, we don't get through to every patient, some still advocate for that test or prescription, but the tools that Choose Wisely Manitoba is developing can strengthen our role as "medical expert" and offer us a tool kit to draw from and allow us to further open up those conversations. We will, however need to move beyond the paper reference materials- utilize the waiting room for educating and leverage technology through social media and patient information resources. I believe we can educate on their terms and must influence on our terms.

Job Titles:

• Director
• Surgeon and Professor of Surgery at the University of Manitoba

Dr Bohm works at the Concordia Hip and Knee Institute in Winnipeg, Canada where he specializes in primary and revision hip and knee replacement surgery. He has undergraduate degrees in both mechanical engineering and medicine from McMaster University, and a graduate degree in Community Health and Epidemiology from Dalhousie University. He completed his orthopedic residency at the University of Saskatchewan, and undertook an arthroplasty fellowship at Dalhousie University in Halifax. In 2009, he completed the prestigious ABC orthopaedic fellowship, visiting the UK, Ireland and South Africa. His areas of research interest include access, appropriateness, effectiveness and safety of healthcare, clinical registries, clinical trials, implant retrieval analysis, and radiographic stereometric analysis. He currently chairs Manitoba's provincial orthopedic standards committee and the advisory committee of the Canadian Joint Replacement Registry. He serves as medical advisor to the Winnipeg Regional Health Authority's orthopedic waitlist, joint replacement registry and central intake program. He is also a member of the George and Fay Yee Center for Healthcare Innovation, where he serves as director of their Health System Performance platform. He is co-lead for Manitoba's Choosing Wisely initiative. Other roles include president of the Canadian Arthroplasty Society, and president if the International Society of Arthroplasty Registries. Dr. Eric Bohm is an orthopaedic surgeon and professor of surgery at the University of Manitoba, specializing in primary and revision hip and knee replacement surgery. He has provincial responsibilities for hip and knee central intake, orthopaedic standards and quality, and the provincial joint replacement registry. He also serves as the Director of Systems Performance at the George and Fay Yee Centre for Healthcare Innovation, and is the Clinical Sponsor for Choosing Wisely Manitoba.

I've been involved with Choosing Wisely Manitoba since its beginning, and I'm pleased to be considered a Clinical Champion. Beyond each of the specific recommendations, we are encouraged as physicians to question the things we're doing on a daily, patient-by-patient basis.

If you're a Canadian over the age of 65, there's a good chance your medicine cabinet is a little crowded. Approximately two thirds of Canadians aged 65 or older are taking five or more prescription medications, with more than a quarter being prescribed 10 different drug classes. In addition, one may be taking over-the-counter medications such as acetaminophen, ibuprofen or supplements. These staggering numbers are one of the reasons why I'm passionate about optimizing medication use and managing polypharmacy through deprescribing.

I'm passionate about antimicrobial stewardship because the evidence is strong: using antibiotics when you don't need them increases the risk of antibiotic resistance, which renders antibiotics ineffective when you need them in the future. If we do not start changing our practice in antibiotic use now, we could be faced with a serious medical crisis. Our future depends on it, as well as the future of our kids and grandkids.

Dr. Terry Wuerz loves problem solving, which is what lead him to Tuberculosis and Infectious Disease. "The field has a strong connection with basic sciences in the field of Microbiology too and I enjoy working closely with the microbiology lab, it is always fascinating to see what kinds of things the lab is capable of doing to help us diagnose and treat our patients." After graduating with his MD at the University of Manitoba in 2007, Terry went on to study long-distance at University of London, obtaining a MSc in Epidemiology in 2019. Terry's specialty is Internal Medicine, and spends a great deal of time working directly with patients, both in clinic, and as a consultant at Health Sciences Centre. Additionally, he also does some clinical research, and teaches undergraduate and postgraduate medical education at the University of Manitoba. His passion project is the Manitoba AMR Alliance, which presents the opportunity to teach about antimicrobial resistance and stewardship to "healthcare workers throughout the province that I have never even met, which is pretty cool!" Learn more about Antimicrobial Awareness from this interview from AMR week 2023.

Job Titles:

• Manager, Blood Management Service, Winnipeg Regional Health Authority

"Considering the importance of Transfusion Stewardship in practices is crucial for health care providers. Asking questions and considering alternatives are important aspects in the use of blood products." said Shauna Paul. Dr. Musuka suggests asking questions before deciding to transfuse: "Is the transfusion of this blood product essential? Can I achieve the same outcome with alternative therapies? What risk do I expose the patient to if I transfuse this blood product?"