What influences clinicians to choose wisely?

Student prerequisites

Must be a current medical student.

How to apply

Contact the first supervisor, Dr Belinda Loring, to express your interest:

Tel
Email belinda.loring@cmc.org.nz

Project brief

Introduction

Choosing Wisely a global initiative, being facilitated in NZ by the Council of Medical Colleges.

Several Colleges and DHB services have developed recommendations about tests, treatments, and procedures that healthcare professionals and patients and consumers should question. Each recommendation is based on the best available evidence. These recommendations are not prescriptive but are intended as guidance to start a conversation about what is appropriate and necessary. As each situation is unique, healthcare professionals and patients should use the recommendations to collaboratively formulate their own appropriate healthcare plan together.

Thus Choosing Wisely encourages health professionals to talk with patients about unnecessary tests, treatments and procedures.
Choosing Wisely has a patient resource on Tests before Surgery when you need them and when you don’t – which covers:

• Pre-op blood tests
• Chest X-Rays
• Spirometry
• Cardiac stress testing

And discusses when these are needed and when not?

http://choosingwisely.org.nz/wp-content/uploads/2018/03/Tests-before-surgery_.pdf

Canterbury DHB has identified that some pre-operative testing is unnecessary under certain circumstances. They are promoting these concepts to clinicians at the DHB via posters, discussions and grand rounds and via feedback on data and evidence related to the pre-op testing.

For example thousands of unnecessary pre-operative CXRs are ordered each year across New Zealand. Only 1.3% show unexpected abnormalities and 0.1% result in modifications in management. Choosing Wisely advice in terms of Pre-operative chest X-rays indicated these are only useful when:

• Acute Cardiopulmonary disease is suspected
• Patient is over 70 yrs with history of cardio-pulmonary disease (and no CXR or CT chest within last 6 months)
• Patient is over 70 yrs with unreliable history and undergoing high-risk surgery

Aim

The aim of this project is to assess if any of these methods; posters, discussions and grand rounds and via feedback to clinicians on data and evidence do actually change clinician behaviour when considering what pre-operative tests to order.

Literature about Choosing Wisely does indicate it is hard to change behavior – many clinicians continue to advise that they do not consider following Choosing Wisely advice because;

• They always have always done it this way
• They want to avoid a complaint so do more tests than necessary may lessen the chance of a complaint 
• They consider the patient wants it
• New tests are good
• The senior doctor requires the test.

This can result in less than ideal care for patients, which may at best add little or no value and, at worst may cause harm.

In this project the student would primarily interview clinicians about their pre-operative testing and if they have changed since learning more about Choosing Wisely recommendations being promoted in the DHB. Thus, to assess what altered their behaviour and if not why not and if so which strategy to promote the change had the most impact.

This would assist understanding of what motivates clinicians to change and to do fewer pre-operative tests or what prevents them “choosing more wisely”.

Method

• Brief literature review on Choosing Wisely initiatives and what motivates behavioural change
• Interviews with clinicians to assess if they changed their usual practice of pre-op testing and if so what influenced their behaviour
• Develop a report with qualitative information gained (and any quantitative data on decrease in testing if possible) and draw some conclusions