Stefan Stefan Hjörleifsson - Choosing sustainability

Transcript

This transcript is AI generated and may contain errors.

Thank you.

Okay, let's start Operating on your own it's not smart So I want to start by thanking a lot of people who have helped me.

Thanks everyone This is young me here looks happy doesn't he this young fellow this is when I signed up for medicine and And what was it I sign up?

something along these lines.

To ease pain and suffering, treat people with illnesses, sometimes prevent them from falling ill, save a few lives, and provide safety at the end of lives.

Something like this.

And all of it within a framework of solidarity, universal healthcare, care according to need, equity.

I'm highlighting that.

A good 30 years later, I can report from the ground as a GP about things that have been making me uneasy for a long time, starting with Sonja, she's having a cold, but we prescribe antibiotics, no big harm but still over treatment.

Norway is the world record holder on MRI, so Erica gets an MRI for her headache.

They find a tiny aneurysm totally harmless and irrelevant, but to Erica it becomes a ticking bomb over investigating over diagnosis.

Peter?

He wants to check his values, blood tests, stop guessing, like in the ad that Margaret McCartney showed us yesterday.

He has no symptoms, no disease, but the vitamin D value is below the reference range.

So Peter gets a prescription and a follow-up appointment, pseudo-disease, overdiagnosis, overtreatment.

And this happens a lot.

I didn't see it coming when I signed up, but we do extensive testing in minor illness and functional disorders, silo disease treatment in multimorbidity, harmful polypharmacy, overtreatment of the frail and dying, overuse of technology, or the medicalization and over use of antibiotics.

How big the problem is?

Well, in your setting, What proportion of healthcare do you consider to be over diagnosis and over treatment?

Anyone?

In my setting, I've been putting this question to the GP trainees in Norway and more than one third of health care is their average estimate.

other estimates OECDs in a report from 2017 saying that about 20% of health care in is waste in the high-income countries and a paper from 2020 about 60% of what we do is high value and evidence-based.

30% waste or low value, and 10% directly harmful for the patients.

Just estimates.

So it's not the exact size of the problem.

That is my main point.

But at least there seems to be a problem, seems the demand is endless and in part driven by supply, supply-induced demand.

It can look like this and feel like these.

And this is not what I signed up for, I feel, to be driving demand for low-value care.

I've been worrying about this for a long time, and for long I didn't know what to do with it.

And you sort of are considered a pain in the ass if you try to bring this up, or at least it was like that for along time.

Now, around when I graduated and started practicing as a doctor, there was this paper in JAMA, the unintended consequences of growth in medical care.

Figure one illustrating the law of diminishing returns, input of healthcare on the x-axis and benefit on y-axes, more and more healthcare giving less and less return.

Eventually the net return can be a harm.

We may now be at point a which is worse than point B.

I'll come back to point T in a moment.

More care can lead to harm through overdiagnosis and over-treatment, distraction, delusion by mild cases or pseudo-disease, opportunity costs.

And it becomes harder to identify and help those who are really in need of care, more mistakes, complications.

Then it's stressful for the doctors, unsatisfying for patients.

If you're unhappy with your the health care you receiving And if you can afford it, you Can go private healthcare personnel may start going private T here starts for stands for tipping point If these harms are allowed to accumulate we may reach a tipping Point the gradual breakdown of universal health Care becoming more and more inevitable This is happening in plain sight as I see it as we speak and it's not what I signed up for.

Sociologist Hartmut Rosa describes what he calls social acceleration, technology speeding everything up all the time, efficiency growth and innovation with the result that we constantly feel that we are running late.

We should be doing more, we should moving faster, a sense of speed and urgency in all areas of life and society.

in the field of health and healthcare.

This drives a constant demand for optimization and technical fixes, no matter what the problem is.

Over-medicalization drives and the market for low-value care drives.

Again, just think of Margaret McCarthy's examples yesterday.

My colleague in Bergen, Norway, Karinne Engen, wrote this analysis paper last year.

Her point of departure is the campaign Doctors Must Live in Norway.

Lager må leve.

Caroline writes about the experience of overwhelming pressure shared by many doctors.

The Doctors must live initiative started when a young hospital tragically took her own life.

It has to do with the high prevalence of emotional exhaustion and burnout.

According to Carolina, the sense of intolerable pressure has do do the loss of fundamental resources in medicine, meaning professional autonomy, caring relations and integrity.

And I would add, and I've been discussing this with Carolina this spring, that it also has to do with the sense of being somehow co-responsible for this erosion of our fundamental resources, this acceleration and provision of low value care.

brings me back to Hartmut Rosa.

His companion concept to that of acceleration is resonance.

Resonance refers to meaningful relationships, meaningful and responsive relationships in which people feel affected by and able to respond to others, activities or environments.

Now, speaking of environment, we only have one planet.

The planet we live on is a limited resource, and we are fucking it up totally.

And the irony being that healthcare is the major contributor to the climate crisis, which harms health.

We've failed to take responsibility for the emergency we're creating.

Now actually though, emergencies, that's something we doctors are equipped to deal with.

And only last week, experts urged WHO to declare the climate crisis to be a global public health emergency.

Depressing.

Sorry about that.

Elvira, did we sign up for such a depressing talk?

Let's do something a little bit else.

Here's a quiz.

There's the quiz, who's that person in the picture?

And there is a prize if you get the name of the person and at least either the year, the occasion, or the city where the pictures was taken.

So there's is prize picture coming now.

Who's this?

Okay, but not just the name of the person.

Occasion, city, year.

Anyone?

Geneva, no.

No.

Any one for the prize?

Row three, row four.

Row four, you know.

You've seen it before.

Bergen people, You must remember.

Hey, Norwegian people.

This is Norwegian history.

So it's Gruhallen Bruntland, of course.

Norwegian doctors used to be our Prime Minister, Director General of WHO and Chair of the UN Commission on Environment.

You almost had it, you'll get the prize, there is the price, here's the surprise.

Launch of The Brundtland Report, London 1987. 1987 yes, look at the definition of sustainable development sustainability in the sense of meeting present needs without compromising the ability of future generations to meet their own needs which allows me to say that overuse is unsustainable in the sense of overburdening system capacity, including the workforce, and it causes moral harm and pollution that is threatening the planet we live on.

And this definitely is not what I signed up for.

I found it quite frustrating.

Somehow, I guess it's common to all of us.

We want to be more part of the solution than part being on the problem side.

This is why I eventually wrote this or co-authored this editorial in the Norwegian Medical Journal as a warning and call to action.

Now here is a timeline and the first two events I've talked about already and then at the turn of this entry we started seeing more solid evidence that medicine causes harm, large scale.

Now the COX-2 antagonist known as Vioxx anti-inflammatory drug withdrawn because of harm and death tens of thousands of people.

2010 Series of papers called less is more in two of the high-profile journals and a paper in the New England Medical New, England Journal of Medicine watershed paper challenging the medical specialties to make Lists of tests and treatments that should be abandoned commonly used expensive not supported by evidence Provided little or no benefit abandoned and make lists and this is what sparked choosing wisely Grassroot initiative profession-led self-critique first in the US It actually fizzled out there quite quickly Would you believe?

Then in Canada, and now we have Choosing Wisely in 25 countries, including four of the Nordic countries.

The core principle, at the heart of Chocing Wisly, look at a description from Canada.

Each college, each health profession making recommendations to avoid the overuse of tests and treatments.

Gradually, I'm glad to say Choosing Wisely has even started to include the climate perspective.

One of the reasons why overuse should be avoided is that it contributes to the crisis.

I became chair of Choosin' Wisly in Norway in 2019. It's been an uphill and unpredictable journey.

As I said, you used to be seen as a pain in the ass if you wanted to discuss harm from medicine, but gradually over use has become a legitimate topic to research and advocate for, well or not advocate against, if you follow me.

But it has been meaningful.

I stepped down as chair of Choosing Wisely last year, but it's been great fun.

Put in a small picture here with a smile, though I'm much older than in the previous picture.

Now here are some quick samples of choosing wisely recommendations from Canada, few from Kluka kliniska val, which is choosing wisely in Sweden, and finally some recommendations from Norway.

Sorry.

Something to discuss with patients these questions Why do you need this test and treatment and what would happen if we weren't to do it?

What are the potential downsides and so on?

And just a word about how the recommendations are made.

They're made by each colleague its specialty each its healthcare profession, but they are shared across the specialties and and even by all the healthcare professions that participates and that's quite cool because it means that the other specialities have your back like if you want to avoid imaging the head of a patient for ordinary headache or avoid Imaging the knee of the midline aged guy like me, then the neurologist and the neurosurgeon have your back or the orthopedic surgeon and physiotherapist have you back because they support the recommendation to avoid these investigations or it was even them who

made the recommendations in the first place.

So here's the figure we had earlier.

If we are too far to the right, so we're not at the top of the curve, we aren't providing maximum benefit.

The idea with choosing wisely is then to reduce medical overuse so that we get less harm.

We get to top the the of curve.

Choosing wisely obviously being just a tool, a brand, movement and the tool.

Of course there are other initiatives to achieve the same, to wind back the harms of too much medicine.

It's also about communicating with patients and the public.

Here are some illustrations that we use in Choosing Wisely Norway to communicate illustrations and phrases.

Actually, I mean, this is illustrative.

I wanted to show this to you, but I also wanted it to share.

It's tricky how to do this, and frankly I never was quite comfortable with these figures.

The big eyes, do you like them?

I was never comfortable.

Even tried to stop the use of these.

Somehow scary.

They all have hyperthyreosis, Graves' disease.

I lost that fight.

The others thought I was over-diagnosing the figures.

Choosing wisely in these four Nordic countries.

Iceland doesn't count here, although Iceland is cool.

Norway has a lot of recommendations and broad participation of medical colleges and other healthcare professions.

There's been slow progress in implementation, but at the moment we have started implementation in hospitals and there is an implementation pilot in general practice that I'll touch on a bit later.

Denmark, that's cool, they have the national patient organization with them and that gives strong legitimacy.

And there's growing awareness in society of the need for resource stewardship that is helpful for Velge Klugt in Denmark.

They have leaned a bit more towards the hospital specialties, but I think that DSAM, the Danish GP College, is fixing that.

In Sweden, GPs have been totally key.

We wouldn't have Krokakliniska Val if it hadn't been for Joosep Hultberg and the Svam Holbard-Hetsrod, so honor and respect to them.

There's a great interest from the authorities in Sweden which is both an opportunity and a challenge.

It can threaten the grassroots and medical professionalism aspect of choosing wisely.

And finally, Finland, or they've been around the longest.

It's more tied up with guidelines in Finland which makes them able to reach the GPs very well.

I'm not sure there's been the same degree of involvement of patients and the public.

But as I said, it's been around since 2016. So if someone can give us evidence that choosing wisely works, It should be the finish.

Please give some evidence.

I'm waiting for that.

One cool thing about reducing overuse is if it frees up resources, then you can increase equity.

We may be providing low value care in some areas, too far to the right, and at the same time in other areas there may groups, patient groups who are getting Less help than they need.

What Margaret calls the patient paradox.

Overtreating the well and under treating the sick, for example.

So choosing wisely reduces overuse.

It should do.

And you can then redistribute to address underuse, increase equity.

And here is the Core Values and Principles document of the Nordic Federation, an important common ground for all of us.

All the core values and principles are interrelated, like number two and three.

We strive to avoid overdiagnosis and overtreatment.

And this should go hand in hand with minimizing inequity.

So choosing wisely, if it is placed within a Value framework like this one.

It can promote equity Back to Norway since that that's where I'm working.

We have just started this implementation pilot one GP office in each of the six municipalities in Vestfold County in the south and GP offices allocate a bit of time To the project they appoint a GP to be to Be responsible for choosing wisely all of them took at course.

We organized including all personnel at the GP office And as a start they had to agree on three recommendations to implement they could choose From this long list And they chose CRP, reducing vitamin D.

We did loads of these tests in Norway.

You wouldn't believe it, we are the world record holders in CRPs.

Our initial results at the pilot GP centers, they say that engaging in choosing wisely actually does not increase the workload.

And they were a bit surprised.

They also find that this choosing-wisely language somehow starts to infiltrate their discussions in a nice way.

Now, for the initial numbers, Vitamin D testing was reduced from early 25 to early 26 by 47 percent on average in all six GP offices ranging from 26 percent to 77 percent reduction and CRP was reduce by 41 percent.

Obviously these are preliminary results come from enthusiast offices Where we can provide follow-up this needs to be scrutinized and we don't know if we kind of scale it and all that But we are working on that We think it's promising And still choosing wisely has important limitations Mainly, we have been trying to avoid harm to individuals.

We have focused too little on workforce sustainability and planetary sustainability.

Also, the gatekeeping role of GPs is under pressure and we need to explain to the public and to patients that gate keeping is done not against the patients but for them and for the system and the individual patient.

Finally, there is something crucially important about fear.

These Choosing Wise recommendations are intended to promote quality and safety.

But everyone is so scared of disease and suffering, And we apply technology constantly to try to keep safe, paradoxically sometimes.

Like here, patients saying, I can't stop thinking about my uncle who died.

He didn't have the investigation before it was too late.

And this is always what scares us.

Let me give you a slightly different take on this example.

This one is afraid of dying, obviously.

But here's another version.

Look at the patient's reply to the right.

This one can't stop thinking about my triathlon results.

So this one is desperate to optimize.

Desperate to own his own health, like you saw in the ad yesterday.

Even if juicing wisely is intended to curb acceleration, that is not enough because fundamentally we need to foster resonance.

More meaningful ways to relate to ourselves, to others, and the world.

Reclaim a language of care, responding to fear with kindness, operating within the boundaries of the human condition and within boundaries the planet.

Yes.

Wow.

What now?

What, now, my friends?

You thought this was a new quiz?

No, no, it was not you have the answer.

It's good No I didn't mean it as a quiz is a good idea, but you can get a price anyway I We are a community of practice with a shared set of values.

These values are expressed in a bold aspirational form in this Nordic Core Values and Principles document from 2020. A lot of bold and smart initiatives by GPs in our countries align with these shared values, not just choosing wisely, far from it.

Bottom-up initiatives based on our shared sets of Look at these potent recent examples.

Two books from colleagues in Denmark and Sweden.

Soon we will all be patients, low value care or non-value care.

Recent newspaper article from a promising young GP colleague in Danmark and one from last week here from Sweden on this bold, potent green practice initiative in the Danish college.

And I also see this Congress as part of our shared policy making, our commitment to sustainability, a commitment, to ensure that the needs for future generations can be met.

And that is something to sign up for and strive for.

That the planet remains habitable and that equitable universal health care survives.

Just look at these examples from the program.

Carbon, sorry.

these examples, carbon footprint, sustainability in education and sickness certification, balancing too much and too little in cancer diagnosis and these urgent topics.

We debate them, we try to shape our shared policy in these areas and if it's so urgent, let's also write about it.

So I'm glad and proud to announce that the Scandinavian Journal of Primary Healthcare is setting out a call for papers on the topic.

Please consider on Monday Monday is the important day somebody said yesterday on Mondays start writing submissions for for this special issue of the Journal more details will be announced Soon so So back to Norway as my final part in some activities and ideas or a plan.

The Norwegian college has been using the heading sustainability in general practice since 2022. We made brochures cups e-learning module proper CME courses podcast climate poster posters about lab overuse if something is urgent we need to take action and we Need to state that it is so we to write and share news about it.

So in the college newsletter, we have monthly a articles about choosing wisely and other sustainability initiatives.

Here is the time needed to treat concept from Inna Johansson news about that and this gets sent to all 9,000 GPs in Norway.

Finally what we are planning in no way and This is work in progress.

It makes me nervous and and curious about your responses now.

I'm sharing something that is Tentative and and we are trying to figure it out We want to make a sustainability program for the GP offices or to be honest We don't even know what to call it.

Perhaps program isn't the right word I thought we might want the certify the officers or at least something they could sign up for honestly we haven't found the right way to describe it so for the time being it is our sustainability thing work in progress obviously picture here from the initial meeting of the working group for college sustainability thing a month ago we wanted to be Theme based or module based and for the entire GP office and not just for each Individual GP like a lot of quality improvement has been until now in in Norwegian general practice We want to launch an early version of the

first modules before the end of this year.

We know more or less What what the contents of these first three?

themes Strands modules are to be bought based on our choosing wisely pilot based and discussions in Norway planning It's not so hard to define the initial contents Of these three strands then some more loose tentative ideas These are all themes or topics that would resonate with the Norwegian GPs.

It might be different in your countries.

Of course, even if the topics are relevant to Gps in Norway, we might still fail spectacularly.

We don't know.

In any case, this is the journey we are on.

All trying to act as stewards of our discipline and stewards the resources in our care.

Struggling and insecure.

But striving for care that is kind and meaningful within the boundaries we face, I believe that as a strong value-based community of practice, we, the GPs in the Nordic countries, can choose sustainability as our guiding principle.

to safeguard universal and equitable healthcare, prevent overuse and ultimately support resilient communities and planetary health.

For me, that is something that seems worth signing up for, and I hope you agree and thank you for listening.

And finally, just a small tip for the rest of the Congress.

Now you've had 30 minutes, even a little bit more than 30, I'm afraid of me.

If this was over treating you, you can take it as a warning.

These are some workshops you might want to avoid.

But if not, then you are very welcome to these good workshops.

See you around and thank you.