Dr. Rory McQuillan is a staff nephrologist and physician who specializes in quality improvement and innovation at the University Health Network. Dr. McQuillan became involved with Choosing Wisely Canada through his interest and training in quality improvement and medical education.
Dr. McQuillan led the development of the Canadian Nephrology Society’s Choosing Wisely recommendations, and helped create complementary patient education materials on Chronic Kidney Disease and Pain Medicines: What to do if you have heart problems or kidney disease.
Dr. McQuillan is also a mentor for the Choosing Wisely Canada STARS (Students and Trainees Advocating Resource Stewardship) campaign. STARS faculty mentors help support students to incorporate Choosing Wisely and resource stewardship into undergraduate medical education curriculum.
Choosing Wisely Canada: How have you incorporated the Choosing Wisely Canada recommendations into your practice?
Dr. Rory McQuillan: When I first became involved with Choosing Wisely Canada, I was very focused on developing recommendations related to dialysis and meal replacement therapy in older adults with co-morbidities. In the 1990s, there was a movement in nephrology to start dialysis when a patient’s kidney function deteriorated to 15%. Since then, we have found that initiating dialysis in older adults may not actually improve their quality of life and longevity. In fact, you may be doing harm to them. Elderly patients on dialysis risk can have higher risks for frailty, falls and cognitive impairment.
With this in mind, we developed the recommendation related to dialysis, emphasizing the importance of waiting until a patient is symptomatic before initiating treatment. This has been a very important change in practice for me as a clinician and my colleagues. It has required us to take a step back and ask ourselves whether dialysis would make a meaningful difference in our patients’ lives; is it truly necessary. We’ve moved away from the practice that a treatment is based on a number.
CWC: What’s your approach to having conversations with patients about things they might not need?
RM: When we developed the recommendations, specifically related to dialysis, we stressed the importance of shared-decision making. The nephrology recommendation, “Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their nephrology health care team,” was developed to encourage clinicians to speak with their patients and always discuss the risks and benefits associated with treatment.
If I have a patient ask me about dialysis, I explain to them that just because this option exists, doesn’t mean it’s right for their treatment plan. We try to help patients understand why a test or treatment may be beneficial in one scenario, and may be unnecessary or harmful in another. It’s stressing the importance of treating each patient individually, rather than offering an option just because it is available. What you realize by discussing the recommendations with your patients is that conservative management can be better than intervention. When we engage in conversations this way, we are empowering our patients to make informed decisions about their care.
CWC: What’s your motivation for being so involved in efforts to reduce unnecessary care?
RM: As clinicians, we need to remember that we should only be intervening when it’s truly necessary. In nephrology, it’s important to be mindful of how treatments can affect our patients and what outcome we want to achieve. Incorporating the mission of Choosing Wisely and its recommendations into your practice is part of honing your skills as a medical expert. It’s about having the experience and confidence in your judgment to know when a treatment or test is beneficial, rather than going through the motions because it’s easier. It has helped us move away from “this is what I always do” and forced us to methodologically think through and articulate our treatment plans with our patients. Clinicians can sometimes fall into patterns of practice, and although there is a role for that in medicine, there is also a role for critical thinking and improving how you care for patients with the best evidence-based practices.