Chair's Article
Dr. Wendy Devinson Thinking Twice/Choosing Wisely

During the last year, I have personally been putting a significant amount of energy into the topic of stewarding finite resources. Part of the strategic plan of the Department of Medicine entitled, “Leading Change: Harnessing Academic Medicine to Transform Health Care”, has been to look for opportunities to improve the stewardship of finite resources. The reason that we need to do this is blaringly obvious. At present, the Ontario government spends 42% of all its tax dollars on health care.1 With an aging and growing chronic disease population, it is incumbent on us to ensure that this very large percentage of the Ontario budget is used wisely and delivers the highest value we can for these expenditures.

This problem is true in many countries around the world. Table 1, which was created from Organisation for Economic Co-operation and Development (OECD) data, shows the percentage of gross national product spent on health care in countries around the world. While we are not as high as the United States, which in 2010 was just under 18%, we do spend over 11% of our gross national product on health care.2 What is most unfortunate about this is that the OECD indicators of quality show that Canada is lagging behind; in fact, we are worse than the United States on some of these indicators. For example, in the Charts 1 and 23 you will see the wait times to see a doctor/nurse in Canada compared to other countries. In Chart 33 you will see and the use of emergency rooms in Canada – note that Canada has the highest percentage of people using emergency rooms during the last year.

Table 1. Total health expenditures as a percentage of gross domestic product (GDP), 1970-2008













United Kingdom

















9.5 (2009)

Unites States







Chart 1. % Same day or next day access to doctor/nurse when sick or in need of care


Same day or next day access to doctor, nurse when sick or in need of care


Chart 2. % Waited six days or more to access doctor/nurse when sick or in need of care


Waited six days or more to access doctor, nurse when sick or in need of care


  Chart 3. % Reporting use of ERs in prior 2 years by country/region


Reporting use of ERs in prior 2 years by country, region


Through my work with the American Board of Internal Medicine Foundation, I have been involved in the evolution of a campaign entitled, “Choosing Wisely”. I am sure that many of you have heard about it from your subspecialty organizations. The American Board of Internal Medicine Foundation worked with many subspecialty societies in the US and asked each of them to create a list of five things for which there was excellent evidence that there was overuse, waste, or even harm to patients. These lists were developed originally by nine subspecialty organizations, but the campaign has grown to include 37 medical societies. Choosing Wisely is a campaign to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. We also partnered with Consumer Report who produced excellent lay versions of these materials to be circulated broadly to the lay public. For those of you who have not seen them, I would strongly urge you to get on the website at and look at what your subspecialty has recommended.

The exciting part is hopefully bringing this to Ontario and Canada. I have been working with a number of colleagues including Drs. Steini Brown, Barry McLellan, Terry Sullivan, Jeff Turnbull, and others, to create a similar campaign here. We have been planning to rebrand the program so it is Ontario and Canadian specific and the title we are working with is, “Thinking Twice”.

The front page of the campaign looks like this.

thinking twice 

To date, we have developed a significant amount of interest from multiple parties including COFM, CAHMO, HQO, MOHLTC, OMA, and CMA who are all interested in working collaboratively to move this forward. CMA has already convened a group of five organizations that are starting to work on their lists and I am meeting with the OMA at a retreat to discuss this shortly. They are eager to participate and move this ahead.

Over the next number of months, I am hoping that a number of you will be excited about being involved in helping your medical subspecialty organizations create your own list of tests and procedures that we should think twice about. We can certainly use the items from Choosing Wisely as a starting place but many of them might not be appropriate to the Ontario and Canadian context and we may have others that we think are more important. We will be developing a strategy to disseminate these lists broadly and to work with the medical societies to promote the stewardship of finite resources.

Physicians are key to helping ensure that the health care system of the future is sustainable and of high quality. While our primary responsibility can be to the patient in front of us we equally have a responsibility to ensuring the quality of the health care system. Thinking Twice is an opportunity to bring our own expertise and knowledge forward to lead these efforts. I look forward to working with some of you personally on this and welcome your input. I am particularly interested to hear what you think of the title, “Thinking Twice”. I will also be giving city-wide medical ground rounds as the FM Hill Lecturer this year on this topic in September.

1 Ontario Ministry of Finance. Strong Action for Ontario: 2012 Ontario Budget.

2 OECD. Health expenditure: Total expenditure on health, % gross domestic product, 2012.

3 The Commonwealth Fund. 2010 Commonwealth Fund International Health Policy Survey.


Wendy Levinson, MD
Sir John and Lady Eaton Professor and Chair
Department of Medicine,
University of Toronto

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