Dr. Christine Soong is Director of the Hospital Medicine Program at Sinai Health System and University Health Network in Toronto. She helped organize and spearhead the development of Choosing Wisely Canada recommendations at the Canadian Society for Internal Medicine (CSIM) as well as the Canadian Society for Hospital Medicine (CSHM).
In addition to her leading role in developing the recommendations, Dr. Soong has been actively involved in putting the recommendations into practice at her hospital. Her first implementation project was reducing unnecessary urinary catheter use among medical inpatients. Expanding beyond local improvement, she partnered with collaborators to understand the magnitude of the problem in a point prevalence study of appropriate urinary catheter use among teaching hospitals in Canada. Through this work, Dr. Soong co-authored the Choosing Wisely Canada toolkit, Lose the Tube.
In addition, Dr. Soong led a project to reduce unnecessary use of benzodiazepines and other sedative-hypnotics (BSH) among older adults at Sinai Health System. This interdisciplinary project, which involved physicians, nurses and administrative staff, focused on the root causes of sedative prescribing such as knowledge gaps among clinicians, outdated order sets, and a hospital environment that resulted in frequent sleep disruptions for patients. The project reduced sedative hypnotic prescribing in older adults by 44% and inspired Dr. Soong to author the Choosing Wisely Canada toolkit, Less Sedatives for Your Older Relatives.
Choosing Wisely Canada: How have you incorporated the Choosing Wisely Canada recommendations into your practice?
Dr. Christine Soong: Working in the Division of General Internal Medicine, I find the recommendations related to internal medicine, cardiology, and geriatrics most relevant to my practice and patient population. Many of my patients are older adults with complex cardiac complications, which is not my specialty. Before referring patients to my cardiologist colleagues, I review the Canadian Cardiovascular Society list to ensure I’m providing the most evidence-based practices for cardiac biomarker testing, stress tests or echocardiograms.
I also find the recommendations are very useful for creating teachable moments with residents and trainees. We use the recommendations in cases and clinical scenarios to discuss when a test or treatment may or may not be appropriate. These situations offer valuable teaching opportunities and I find trainees are eager to incorporate Choosing Wisely into their practice.
CWC: What’s your approach to having conversations with patients about things they might not need?
CS: Counseling around medications, tests, and treatments is something we do every day, but we don’t routinely tell patients why not to take a medication or why we shouldn’t order a test.
The Choosing Wisely recommendations and principles can help when talking to patients if they ask for something specifically. For example, if a patient says “I have sleeping problems, will a sleeping pill help?” We can use the recommendations as a way of discussing risks and alternatives to treating the problem. It allows us to have a dialogue about appropriateness. As a physician, I feel good about these conversations because I’m involving patients in the decision-making related to their care.
CWC: What’s your motivation for being so involved in efforts to reduce unnecessary care?
CS: We as clinicians, physicians, and prescribers have a responsibility to be mindful and only use appropriate interventions when delivering care. I think the reason we have so much inappropriate overuse in health care, and therefore need a campaign like Choosing Wisely, is because of the misconception that “more is better” and we think that if there are advanced therapies, we should offer them. But as a physician, I think it is part of our professional duty to practice more restraint. If we order a scan and see something come back, we have a reflex to investigate it further. But I believe the more appropriate approach is having a conversation with your patient and understanding their goals and values. It is important to ensure that patients understand what your discussing when it comes to their health and potential course of treatment; don’t just assume what the next steps are in their care. I think if we constantly assume what our patients want, we are passing our values on to someone else. However, if we have these types of conversations, we can facilitate more informed decision-making and provide the most appropriate care plan.