Episode 27: Trust as a barrier and facilitator in choosing wisely

Voiceover:

Welcome to the NPS MedicineWise podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Jill Thistlethwaite:

Hello. My name is Jill Thistlethwaite, and I'm a GP and medical advisor at NPS MedicineWise. Today we're going to talk about the Choosing Wisely National Meeting. Choosing Wisely Australia is part of a global healthcare initiative to improve the safety and quality of healthcare. Launched in Australia by NPS MedicineWise in 2015 in partnership with Australia's health professional colleges, societies and associations, Choosing Wisely Australia challenges the way we think about healthcare, questioning the notion, more is always better. Choosing Wisely Australia is modelled on the Choosing Wisely campaign, which was launched by the ABIM foundation in the United States of America in April 2012. Today I have two guests with me on the podcast. Dr Robyn Lindner, who is executive sponsor for Choosing Wisely Australia and provide strategic direction and managing strategic directions for the initiative is joining me for NPS MedicineWise in Sydney, Australia. And Tara Montgomery, who is a public health advocate and communications strategist at Civic Health Partners in the United States joins us on the line from New York City. Welcome Robyn and Tara.

Robyn Lindner:

Hi Jill, thanks for having me.

Tara Montgomery:

Hi, I am thrilled to be here.

Jill Thistlethwaite:

Great. So Robyn. You've been instrumental in the Choosing Wisely Australia movement since its inception. I'd like to start by asking you a little bit about why a movement like Choosing Wisely Australia is needed. As a catalyst of public discussion, Choosing Wisely Australia encourages conditions and consumers to have better conversations about what care is truly needed, identifying which practices are helpful and which are not. You've been involved in Choosing Wisely Australia since it kicked off here about six years ago. Why do you think it's needed in Australia?

Robyn Lindner:

That's a good question, Jill. And I think there's probably a couple of layers to the answer in terms of why Choosing Wisely is needed in Australia. So to start with at its heart, Choosing Wisely is about resource stewardship. So it's about recognising that the health system, like any system, has only a finite amount of resources. And so what we want to make sure is that those resources are going to the people who are going to absolutely benefit the most from those resources. And I think COVID has been a really nice example of really shining a light on how fragile the system can be when there's a strain put on it in terms of resourcing.

The other layer to this is the fact that it's very well understood that there is a significant amount of waste or unnecessary care that happens in the health system. So as much as 20% of healthcare delivered in Australia, so tests and treatments and procedures, has been deemed as what we would call low value. So that means that there's no net benefit to the patient in terms of receiving that care. So that's a problem.

Then we layer on top of that, the fact that majority of health professionals believe that they have a responsibility to manage the appropriate use of these finite resources, but they will acknowledge that patient expectations around what care they should receive will drive them sometimes to employ healthcare that they know is actually not necessarily going to benefit the patient. So there's a gap between the aspirations of a health professional in terms of delivering healthcare and sometimes what they actually deliver.

And then on top of that, when we survey consumers about what their experience is when they see a healthcare professional, they will say that we just do what the health professional tells us. So we've got health professionals saying that patient expectations are a major driver for unnecessary care. And we've got patients saying, well, I just do what the doctor tells me.

So all of that tells us that there's a need for better conversations and communication between health professionals and consumers, about what care is actually appropriate so that people get the care that's right for them. And that's really what's at the heart of Choosing Wisely and why I think that Choosing Wisely is important in Australia.

And the benefit out of all of this is that if we engage in good conversations about appropriate healthcare and participate in what we call shared decision-making, there's good evidence to show that there are better outcomes for patients if we do that.

Jill Thistlethwaite:

And it's such an important initiative on so many levels, but how well do you think it's been received in Australia?

Robyn Lindner:

Well, I think it's been received quite well. And I would, the reason I would say that is because the whole reason that NPS MedicineWise actually introduced Choosing Wisely into Australia was demand driven from health professionals. So there were health professional organisations saying to us, we think this is a really important initiative and we think it should be here in Australia. And from initially when we launched, we had six medical colleges on board.

We now have close to 50 health professional organisations on board representing over 90% of the health professional specialties in the country. So we've got general practitioners, physicians, surgeons, physios, nurses, pharmacists. So a really broad range of health professional organisations have identified that this is an important initiative and have wanted to be a part of it.

But importantly, on top of that, the key health consumer advocacy organisations have also identified and recognise that this is an important initiative as well, and have signed up to the initiative as well. And we're really proud that Consumers Health Forum, which is the peak consumer advocacy group in Australia, was one of our founding members for the organisation.

And then on top of that, we've got an increasing growing network of hospitals and health services that are volunteering to sign up to the initiative and actively implementing programs across the country, aiming to reduce unnecessary care and improve their engagement with consumers.

So it's very much a grassroots led initiative. And I think that's the thing that's been attractive to both Australian consumers and health professionals in terms of why they've wanted to be involved because it's about giving leadership and ownership to the people at the front line in delivering care, to identify where we can make improvements, and then to implement those changes.

Jill Thistlethwaite:

Oh, and it's just great to hear about the number of health professions that are involved and the consumer involvement, everybody working together in collaboration.

So Tara, thank you for joining us all the way from America's East Coast. Choosing Wisely, as we've heard is a clinician led initiative with health professional bodies, reviewing the evidence and identifying tests, treatments, and procedures that shouldn't be done. You spearheaded the original consumer campaign in the United States. Can you tell us about why it's important to engage health consumers in the Choosing Wisely campaign?

Tara Montgomery:

Yes. And again, I'm so pleased to be here Jill. As Robyn said, this campaign really has been a grassroots campaign and the Australian campaign has stayed true to the original intention for it to be that way. And I think if you think about it that way, it's completely normal that consumers should not only be engaged, but involved from the very beginning. And that is what happened. It's actually a 10 year anniversary this summer of the first meeting where Choosing Wisely was conceived and consumers were in the room at that very first meeting before the campaign even had a name. And so it has been about involvement and participation and increasingly co-creation.

And that really matters because healthcare is about patients and consumers, and it would really be wrong for us not to be engaged from the beginning and engaged throughout. So I'm happy that that has happened in this campaign.

I think another important point is that Choosing Wisely has always been a culture change initiative. It hasn't been a traditional quality improvement project or cost savings program or anything. It has been much more about conversations. And social scientists can tell you that conversations are really at the heart of culture change that what makes culture change happen. And so you need to have different parties at the table to have those conversations and including engaging consumers in conversations with physicians, pharmacists, and others who are involved in delivering care is incredibly important if you want to arrive at culture change. And that's a very long-term thing to attempt, and that's why we're already nearly 10 years into this campaign.

And those conversations have been happening in different levels, in different places and all around the world. And they're very important with Choosing Wisely because the messages of Choosing Wisely are often counter-intuitive, and you've already heard Robyn talk about how we need to shift the thinking from ‘more is better’ to a more nuanced shared decision-making model. And so when you have those counter-intuitive messages, really you need thoughtful conversations between physicians and patients, where people are working from the same base of evidence and engaging together on evidence that may not be familiar to either the physician or the patients. And so that's a really essential part of shared decision making, and I'm excited to see how it's been leading to change.

Jill Thistlethwaite:

So you mentioned there Tara about the importance of culture change. I know that you've been involved in research on these issues in many different countries around the world. So what's the impact on this initiative of different cultures that you've been involved with? So we're talking about culture in general, but then the cultures around the world on these issues. Can you tell us a bit about that?

Tara Montgomery:

Yeah. Well, culture and systems are very intertwined if you like. And I would start by saying, although there are a lot of differences in both systems and cultures, there are also a lot of similarities around the world and the OECD has looked at this and they measure global healthcare performance. And what a lot of countries have in common is that healthcare costs are rising faster than national economies. So we have a shared problem.

But where there is difference is around the local regional variation in what that problem looks like on the ground. And that is often based on how the systems are different, which as we know in some countries with a national health system, that may be both love for that system, but also concern that the system is under pressure to ration care.

In other countries that are very commercialised and consumerised in the healthcare system, patients are expected to act like consumers, to be demanding services, looking for value for money, but also afraid of being ripped off by people trying to profit from them.

So there's systemic differences linked to cultural differences. And Australia, I think, sits in the middle there in terms of its healthcare system. And in fact, in terms of patients' trust in that healthcare system.

But the cultural differences. They're not only between countries, they're often inside of countries, and I think that's something we've been learning to reflect more upon as the program has progressed and large countries have very different delivery of different health services from one territory or state to another. And so those variations really mirror the variations we see between countries.

I would say that there are countries with cultures where the population, where the citizens have a different attitude towards their doctors. So some feel very entitled to ask questions. Others definitely do not and have more of a traditional structure of reverence and deference towards the doctor and not wanting to question them, wanting to ask, to be told what to do and not show disrespect and others want to include their whole family in a decision and bring everyone into the room for a big medical decision.

So you see different relationships with doctors, and that makes a difference to how the campaign needs to be tailored to different cultures and communities. And again, we've learned over these years, that one message, one campaign, one set of assumptions is not appropriate at all globally, or even within a country. And that that tailoring, to be culturally sensitive, is incredibly important and actually has a big impact if you do it right.

Jill Thistlethwaite:

Yeah, absolutely. Very important, and just resonates with how we work as clinicians certainly. The reason we're having this conversation today for this podcast is that we're about to hold the annual Choosing Wisely Australian National Meeting, which is on Wednesday, the 19th of May. Obviously this show, it's going to be a virtual event with the theme of empowering consumers to choose wisely.

Robyn, you're leading the team that's preparing the program. What can we expect?

Robyn Lindner:

Well, I'm hoping that we will have a very exciting conversation about the work that's happening both internationally, so hearing Tara's perspectives there, but also what's happening locally in terms of efforts to support and empower consumers to be active participants in their healthcare, but also in terms of the work that can be done to help and support health professionals as being partners in healthcare delivery. So, as I said, we're going to be hearing international perspectives, but we're also going to be hearing some directly from people who are working at the coalface in health services, delivering care, and talking about the innovations that they've been doing to employ a more consumer centric approach to the work that we're doing.

We're going to be hearing from expert researchers in this space who understand health literacy and talking about where the opportunities are to leverage Choosing Wisely to improve health literacy for Australians. And I think it'll be important to, and I'm interested to be hearing about, putting all this into the context of COVID pandemic and what have we learnt about ourselves in terms of our understanding about risks and benefits of healthcare and how can we leverage those insights to actually help progress the initiative and improve delivery of care in Australia.

Jill Thistlethwaite:

So a lot to look forward to. And Tara, you're going to be providing the international keynote address. Could you tell us a little bit about that without giving away too many spoilers?

Tara Montgomery:

Absolutely. And Robyn the agenda sounds amazing. And I will probably be up all night on New York time to catch as much as I can.

Jill Thistlethwaite:

And it will be well worth it.

Robyn Lindner:

Yes. We'll send you some coffee.

Tara Montgomery:

Thank you. Yes, so I will be speaking about trust and the relationship between Choosing Wisely and trust. And why I want to bring this conversation to the meeting is that really at the beginning of the formation of Choosing Wisely, we discovered very quickly both with physicians and with patients that trust was both a barrier and facilitator to the acceptance of the Choosing Wisely message. And some people may or may not trust the evidence, trust the messages itself, themselves, trust the messengers.

And so we've learned a lot about how to think about, how to package the evidence, how to test messages, how to choose messengers, who people can trust more easily. So I want to talk about how that has looked over the evolution of the program around the world. And also think about how trust has changed and how it might be impacting the future of Choosing Wisely.

Over these same 10 years, the state of trust in the world has really changed. So the Edelman Trust Barometer, which measures trust in different countries, trust in institutions, governments, science, experts has seen a real erosion in trust in many countries. Less so in Australia, I might say, but it's still very interesting in the United States and Europe to see how that erosion and trust is impacting trust in healthcare, and actually could undermine acceptance of Choosing Wisely, if we don't get ahead of that and think about how to engage consumers around really building trusting relationships. And that's both at the broad, systemic and cultural level, but also at the level of a physician patient relationship or a pharmacist patient relationship.

So I want to reflect on what I've learned in my research on trust and how that has varied around the world and how trust during the era of COVID has also had an impact on how people think about tests, treatments, and procedures, and think about the healthcare system in the country where they live. In certain countries that have had massive failures in their COVID response, public trust in healthcare has really declined further. In other countries, maybe trust has increased because of the heroism of the healthcare system.

And so we need to be really aware of how those trust climate are changing so that we can really stay current in the way we communicate with the public and have an understanding of really the temperature of the public sentiment around public health communications. And I think, I have a lot to learn from you in Australia about this, but also hopefully a lot to share about how difficult that has been in the United States, where trust has really been in a state of crisis in the past year and trust in science has been seriously challenged.

So I want to have that conversation. And finally, I want to think about how trust also intersects with equity issues and in every country around the world, this has been a year of really reflection and outrage about inequity. And there are lots of examples of how that has come to the surface in the past year. And it really is a call to action for us all to think more about equity in Choosing Wisely and how trust with different kinds of communities is very important to earn, not just ask for, as we move forward with the campaign.

Jill Thistlethwaite:

I think anyone listening to this podcast now is just going to be thinking, I really need to hear more, because they’re just such important topics. And for those listeners who are interested, I do encourage you to register for the 2021 Choosing Wisely Australia National Meeting, the virtual event, on Wednesday the 19th of May.

I'd like to thank Tara and Robyn for joining us in this really interesting conversation. And I'd also like to point out that the Choosing Wisely National Meeting directly follows on NPS MedicineWise other key annual event, the National Medicines Symposium, which is on Tuesday, the 18th of May. And that has the theme evaluating quality use of medicines, how do we know if we're making a difference. Registration for both events is now open at $100 dollars for the individual online events, but registration does close on Friday the 14th of May. So don't miss out on these, hearing Tara telling us more about trust and equity.

Find out more about both events on the NPS MedicineWise or Choosing Wisely Australia websites, or check out the further links in the podcast notes. So once again, thank you Tara and Robyn, and we all very much look forward to the virtual event. Thank you, and goodbye.

Voiceover:

For more information about the safe and wise use of medicines, visit the NPS MedicineWise website at nps.org.au.