From longer wait times to lengthy travel, rural and northern Ontario communities face unique barriers to accessing health care. How can Choosing Wisely Canada recommendations help address these challenges, and what limits their adoption?

That’s what Div Patel and Nathan Jeffery, STARS (Students and Trainees Advocating for Resource Stewardship) student leaders at the Northern Ontario School of Medicine (NOSM) University, set to find out. In 2025, they co-led a qualitative study on how Choosing Wisely Canada recommendations have been implemented in primary care settings since the COVID-19 pandemic.

For both students, early experiences shaped their focus in this research. Nathan’s interest began when he moved from Toronto to South River, Ontario, a town of just 1000 people. He saw firsthand to the challenges that patients face when trying to access health care in rural communities, inspiring his pursuit in medicine. While training primarily in rural communities at NOSM University, Div saw just how limited health care resources can be, and that unnecessary treatments not only create waste, but can limit access for other patients.

“We saw firsthand the challenges physicians and patients faced in accessing care, especially as the pandemic changed how primary care was delivered,” says Nathan. “With virtual care, fewer in-person assessments, and overall system strain, we began to wonder how physicians in rural settings were using resource stewardship to improve the health care system.”

Drawing on these experiences, the co-STARS surveyed 127 primary care physicians across Canada. They found that awareness of Choosing Wisely guidelines was high at 97% but putting them into practice remained a challenge. Barriers included limited local resources, time constraints, patient expectations, and fear of missed diagnoses. The study also found that integrating resource stewardship is challenging in rural areas where follow-up and diagnostic resources are limited. In these settings, physicians often must adapt guidelines to fit local realities. Making recommendations easier to use, such as embedding them in electronic medical records, was highlighted as a way to improve uptake.

With the support of their faculty advisor, Dr. Roy Kirkpatrick, their research has now been accepted for publication in the Canadian Journal of Rural Medicine, and both Div and Nathan were recognized as SuperSTARS at the 2025 Choosing Wisely National Meeting to share these findings.

Looking ahead, Nathan is continuing to mentor other NOSM University students about resource stewardship through the Choosing Wisely interest group he helped establish. Both he and Div are serving on the 2025 STARS Trainee Advisory Committee, to provide feedback on projects for new participants. As he begins his psychiatry residency training, he hopes to help patients in rural communities receive better access to mental health care, and one day advise on recommendations in psychiatry and rural medicine. This fall, Div is starting family medicine residency at Queen’s University, where he plans to continue applying resource stewardship principles to his practice, combining clinical work and advocacy .

“By using our limited resources more efficiently, we can improve access to care and ensure the system remains sustainable for patients and communities,” he shares. “I hope to continue research that reduces low-value care and strengthens efficiency, so that both rural and urban patients can benefit from more equitable, accessible, and sustainable health care.”

Div and Nathan hope their research will guide practical solutions that reflect the unique needs of the communities that physicians serve.  They look forward to continuing this work that ensures care is more accessible and equitable across Canada.