Dr. Bushra Khan is a first-year psychiatry resident at the University of Toronto. Dr. Khan completed her medical education at McMaster University. During her first year of medical school, she participated in the first STARS Leadership Summit. As an active STARS student leader, she founded the McMaster Resource Stewardship Interest Group, 2 student-led conferences on resource stewardship and helped lead the integration of Choosing Wisely Canada into pre-clerkship curriculum at McMaster University. She has been actively involved locally and provincially as a leader through roles as the Director of Communications for the Ontario Medical Student Association.
Choosing Wisely Canada: How have you incorporated the Choosing Wisely Canada recommendations into your practice?
Bushra Khan: By participating in STARS during my first year of medical school, I learned about resource stewardship very early in my training. This has influenced me throughout clerkship and now in residency. In clerkship, I integrated Choosing Wisely Canada recommendations during my internal medicine rotations where you often have broad differential diagnosis, and in emergency medicine as I would consider approaches to diagnosis for common complaints. During my rotation and on call shifts, I would look at radiology and other lists, and would find Choosing Wisely was brought up a lot related to panels you can order. Preceptors would ask – do you think it’s worthwhile to order specific panels? Is that information giving you something you didn’t already know?
An important thing for medical students to demonstrate is that they are able to consider the breadth of things and diagnoses that exist but know that one is more likely than the other. Preceptors often question students about what information you need not just from your patient, but also from investigations to help you get there, to making a diagnosis.
Choosing Wisely Canada recommendations helped me have the confidence in answering those questions and helped to solidify my learnings. I felt comfortable explaining to preceptors the reasoning behind why I did and also did not order certain tests. For psychiatry, my chosen specialty, I rely on Choosing Wisely principles in particular in interviews and asking patients the right questions to understand their history.
CWC: What is your approach to having conversations with patients about things they may not need?
BK: I am still very early in my training. Conversations are a foundational part of psychiatry, but especially in the hospital setting. Patients will have a lot of variation in terms of their capacity, understanding and ability to consent. Some cannot if they are in crisis, or due to the nature of their illness. Yet, you need to have conversations with patients and their families to manage expectations and make challenging treatment choices. In particular, I see that there is a need to improve communications about what medications can and cannot do and to discuss evidence for non-pharmacological therapies. I also see Choosing Wisely helping to inform challenging conversations with families of patients or people’s social supports. Family or social support involvement are so important to recovery and mental health in communities, so involving families in shared decision making is essential.
I know that the Four Questions are intended to support patients and families asking questions, but I find that I also use them for self-reflection as I study and learn new information. I find myself asking the question – does the patient need this? What are the alternatives? So for me at this stage as a trainee communication is not just with the patient but also with my peers in small group learnings, with preceptors, and also through self-reflection and critical thinking. At this stage of practice, I am not the one who signs off on whether or not the patient gets an MRI, but I can be critical and reflect on the utility of that. I think that’s different than being out in practice, reading the list and then having to incorporate it, it has shaped my clinical practice because I learned it from the ground up as opposed to the top down.
CWC: What is your motivation for being so involved in efforts to reduce unnecessary care?
When I first applied to participate in STARS I had a limited understanding of patient safety and quality. My own personal motivations for getting involved were that I truly believe that more is not always better. When I saw that as the tagline, that’s not a well-understood perspective in our society, not just medicine. I love the idea behind STARS which is that if you learn something early on in training it can inform your ongoing training and future practice. Because I had interest and exposure to STARS, I could see issues of poor management of resources within the system through some advocacy work that I did with provincial associations and I wanted to make evidence-based choices in my own clinical work to try to address this with every patient contact I have.