Choosing Wisely (Patients)

Choosing Wisely (Patients)

Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.

How CWC Helps Both Clinicians and Patients

Choosing Wisely Canada (CWC), uses plain language and patient-friendly materials to complement the lists of “Five Things Clinicians and Patients Should Question.”

The materials are meant to help patients learn about the tests and treatments in question, when they are necessary and when they are not, and what patients can do to improve their health.

CWC has launched a patient facing campaign entitled, More Is Not Always Better, to promote the message that in medicine as it is in life, “more is not always better”, educate patients about when they might need a particular test or treatment, and when they don’t, and encourage patients to talk with their doctor about unnecessary care.

What Makes CWC a Great Resource

Unnecessary tests, treatments and procedures do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives and contributing to stress for patients. And of course unnecessary tests, treatments and procedures put increased strain on the resources of our health care system.

Canadian national specialty societies participating in the campaign, representing a broad spectrum of physicians, have been asked to develop lists of “Five Things Physicians and Patients Should Question.” These lists identify tests, treatments or procedures commonly used in each specialty, but are not supported by evidence, and/or could expose patients to unnecessary harm.

Choosing Wisely Canada is modelled after the Choosing Wisely® campaign in the United States, which was launched by the ABIM Foundation in April 2012.
Choosing Wisely Canada is organized by Dr. Wendy Levinson in partnership with the Canadian Medical Association.

Choosing Wisely Canada got underway initially in Ontario and has quickly been adopted by all provincial and territorial medical associations which have established or are in the process of establishing mechanisms to support the adoption of the Choosing Wisely Canada lists. It is now a truly national campaign in Canada and, in fact has spread to Australia, Germany, Italy, Japan, Netherlands, Switzerland and elsewhere. Choosing Wisely Canada leads the international effort.

Choosing Wisely Canada recognizes the importance of educating and engaging patients so that they could make informed choices about their care. This campaign has created patient-friendly materials to help patients learn about the tests, treatments or procedures in question, when they are necessary and when they are not, and what patients can do to improve their health. Choosing Wisely Canada is working with various stakeholder groups to disseminate the patient materials widely.

Choosing Wisely Canada is also working with medical schools to introduce new content into the undergraduate, postgraduate and continuing medical education curricula.

Opportunities are currently being identified, through partnerships with various health care organizations and associations, to support implementation of the physician recommendations in practice settings. Choosing Wisely Canada has recently introduced an “Early Adopter Collaborative” to bring such groups together.

The lists of “Five Things Physicians and Patients Should Question” are not intended to be used to establish payment and coverage decisions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, physicians and patients should use the Choosing Wisely Canada materials to determine an appropriate treatment plan together.

Bone-density tests: When you need them—and when you don’t

A bone-density test is a way to measure the strength of your bones. The test, called a DEXA scan, is a kind of X-ray. Many people get a bone-density test every few years. The main reason to have the test is to find and treat serious bone loss, called osteoporosis, and prevent fractures and disability. Most men and women under age 65 probably don’t need the test because:

Most people do not have serious bone loss

Most people have no bone loss or have mild bone loss (called osteopenia). Their risk of breaking a bone is low so they do not need the test. They should exercise regularly and get plenty of calcium and vitamin D. This is the best way to prevent bone loss.

The bone-density scan has risks

A bone-density test gives out a small amount of radiation, but radiation exposure can add up. The effects can add up in your body over your life, so it is best to avoid it if you can.

Who should get a bone-density scan?

Women should get a DEXA scan at age 65, and men age 70 and up. They may want to talk with their doctors about the risks and benefits before deciding. Younger women and men ages 50 to 69 should consider the test if they have risk factors for serious bone loss. Risk factors include:

  • Breaking a bone in a minor accident.
  • Having rheumatoid arthritis.
  • Having a parent who broke a hip.
  • Smoking.
  • Drinking heavily.
  • Having a low body weight.
  • Using corticosteroid drugs for three months or more.
  • Having a disorders associated with osteoporosis.

You may need a follow-up bone-density test after several years, depending on the results of your first test.

If you do have bone loss, you may be offered drug treatments

The most common drugs to treat bone loss are Fosamax (generic alendronate) and Actonel (generic risedronate). These drugs have benefits and risks to think about and discuss with your doctor. Common side effects include upset stomach, difficulty swallowing, and heartburn. Rare side effects include bone, joint and muscle pain, cracks in the thighbones, bone loss in the jaw, and heart rhythm problems. Other drugs used to treat bone loss also have risks, including blood clots, heart attacks, strokes, and serious infections. The treatments have limited benefits in some patients. Many people are given drugs because they have mild bone loss, but there is little evidence that these drugs help them. Even if the drugs do help, they may only help for a few years, so you may want to consider them only if you have serious bone loss. Mild bone loss is better treated with exercise, vitamin D and calcium.

How can you keep your bones strong?

The following steps can help you build bone:


The best exercise for your bones is exercise that makes your bones carry weight. When you walk, your bones carry the weight of your whole body. You can also lift weights. Aim for at least 30 minutes of weight-bearing exercise a day.

Get enough calcium and vitamin D

They help keep your bones strong.

  • Aim for at least 1,200 mg of calcium a day. Eat foods high in calcium, such as dairy products, leafy green vegetables, and canned sardines and salmon. You may need a calcium pill each day.
  • Consider taking vitamin D if you are a woman in menopause or you get little sun. Take 800 IU a day.
Avoid smoking and limit alcohol

Among other things, smoking and drinking alcohol can speed up bone loss.

  • Try a stop-smoking program. Ask your doctor about a nicotine patch or other treatments.
  • Limit yourself to one drink a day for women, and two drinks a day for men, unless you have medical reasons for tighter limits.
Try to avoid certain drugs

Some drugs can damage bones. These include proton pump inhibitors (common ones are omeprazole, lansoprazole, and pantoprazole), used to treat heartburn; corticosteroids; and some of the newer antidepressants. If you take one of these drugs, ask your doctor about whether these medications are right for you.

Vitamin D tests: When you need them—and when you don’t

Many people don’t have enough vitamin D in their bodies. Low vitamin D increases the risk of broken bones. It may also contribute to other health problems. That’s why doctors often order a blood test to measure vitamin D. But many people do not need the test. Here’s why:

A test usually does not improve treatment

Many people have low levels of vitamin D, but few have seriously low levels. Most of us don’t need a vitamin D test. We just need to make simple changes so we get enough D. We need to get a little more sun and follow the other advice on the next page.

Even if you are at risk for other diseases, like diabetes and heart disease, a vitamin D test isn’t usually helpful. The test results are unlikely to change the advice from your doctor. It is much more important for you to make lifestyle changes first—to stop smoking, aim for a healthy weight and be physically active. And, like most other Canadians, you should try to get enough vitamin D from sun and foods. And talk to your doctor about supplements.

Extra tests lead to extra treatments

Getting tests that you don’t need often leads to treatments you don’t need, or treatments that can even be harmful. For example, if you take too much vitamin D, it can damage your kidneys and other organs.

When should you have a vitamin D test?

Talk to your doctor about your risks. Here are some conditions where you might need a Vitamin D test:

  • If you have osteoporosis. This disease makes your bones weak, so that they are more likely to break.
  • If you have a disease that damages your body’s ability to use vitamin D. These are usually serious and ongoing diseases of the digestive system, such as inflammatory bowel disease, celiac disease, kidney disease, liver disease and pancreatitis.

If your doctor suggests getting a vitamin D test, ask about your risks. If your risk is high, you should get the test. If your risk is low, ask if you can avoid the test. Ask if you can boost your vitamin D with sunlight and food, and possibly supplements.

If your doctor needs to keep track of your Vitamin D, make sure the same test is used each time. Ask your doctor which tests are best.

How can you get enough vitamin D?

The recommended dietary allowance (RDA) per day is 400 IU (10 mcg) for children

Get some sun

The sun’s ultraviolet rays create vitamin D in your skin cells. You don’t need a lot of sun. Depending on the amount of skin exposed and sunscreen used, a 10-minute walk in the midday sun can create as much as 15 times the amount of vitamin D that you need every day. Your body stores some of the extra vitamin D to help you in the darker winter months.

Eat foods that are rich in vitamin D
  • Meat, poultry and fatty fish are rich in vitamin D.
  • A small serving (85 g) of salmon has 530 IU.
  • Shrimp, mackerel, sardines and fresh herring also are rich in vitamin D.
  • Vitamin D is added to some foods, including tofu, orange juice, and some dairy products.
Eat breakfast

Two eggs, a glass of orange juice (not from concentrate) and a bowl of cereal with milk can add about 300 IU of vitamin D a day.

Talk to your doctor about supplements

If you don’t get much sun and your diet is low in vitamin D, a supplement may help.

Do not take more than 4,000 IU of vitamin D a day unless your doctor has advised you to do so. Too much vitamin D can be toxic and can damage your kidneys.

Treating osteoarthritis of the knee: Popular supplements don’t work

Osteoarthritis is the most common type of arthritis, affecting 1 in 10 Canadian adults ( The knee is one of the most common and most symptomatically affected joints, causing knee pain in many people. They often try over-the-counter remedies to help the pain, and to avoid knee surgery. Amongst these treatments are the supplements glucosamine and chondroitin sulfate, which are very popular.

Because glucosamine and chondroitin are building blocks of cartilage, and because osteoarthritis is related to cartilage degradation, many believe that adding these building blocks to the diet of a person suffering from osteoarthritis will help rebuild cartilage and lessen pain. While on the surface this may seem logical, in reality these supplements do not provide effective pain relief. Here’s why:

These popular supplements don’t work

Many studies have shown that glucosamine and chondroitin sulfate do not help to relieve pain from arthritic knees. People who take the supplements often report less pain or swelling of their joints. But people get similar results if they take a placebo—a “sugar pill” with no active ingredients. Pain relieving drugs, such as acetaminophen (Tylenol and generic) and ibuprofen (Advil, Motrin IB and generic), help a lot more.

The supplements can be dangerous

Glucosamine and chondroitin are not harmful by themselves, but they can interact with other medicines. For example, the supplements can increase the effect of warfarin (Coumadin and generics) on blood clotting. This increases the risk of bruising and serious bleeding. Problems with warfarin frequently lead to emergency room visits.

You aren’t always getting what you think

To make matters worse, often the labels on the bottles are misleading. In 2013, Consumer Reports tested 16 joint pain supplements and found that seven had less chondroitin than the label listed.

Other approaches often work better

There are more effective ways to relieve arthritic knee pain:

  • Physical therapy
  • Losing weight
  • Acetaminophen (Tylenol and generic)
  • Ibuprofen (Advil, Motrin IB and generic)
  • Naproxen sodium (Aleve and generic)
  • Other anti-inflammatory medications

If these don’t help, you can talk to your doctor about treatments such as injections or surgery.

Steps to help ease the pain of osteoarthritis of the knee

Lose excess weight

Losing a pound of excess weight can take about four pounds of pressure off your knees when walking.

Physical activity

To build support of the knees, do strength training, especially of the quad muscles on the front of the thigh. Aerobic exercise builds strength and can reduce pain. Stretching can help prevent stiffness. Ask a local YMCA or gym about exercise programs for people with arthritis.

Mechanical aids

A cane, crutch, or walker can take a load off painful knees.

Heat and cold

A heating pad can ease ongoing stiffness and soreness in joints. For acute pain and swelling, switch to ice packs.


Deep-tissue massage got high marks in a 2010 survey of Consumer Reports online readers. Half of them said that it “helped a lot” with their osteoarthritis.

Use drugs carefully

Ibuprofen (Advil, Motrin IB and generics) and naproxen (Aleve and generics) can ease pain and inflammation. But they may cause stomach bleeding and high blood pressure, if taken over a longer time. Try to use them only for short periods.
Acetaminophen (Tylenol and generic) can also help reduce pain, but high doses can damage your liver. Make sure you take less than 4,000 mg a day.

Imaging tests for lower back pain: When you need them—and when you don’t

Back pain can be excruciating. So it seems that getting an X-ray, CT scan, or MRI to find the cause would be a good idea. But that’s usually not the case. Here’s why:

They don’t help you get better faster

Most people with lower back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery. For example, one large study of people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an over-the-counter (OTC) pain reliever. Another study found that back pain sufferers who had an MRI in the first month were eight times more likely to have surgery, but didn’t recover faster.

They can pose risks

X-rays and CT scans expose you to radiation, which can increase cancer risk. While back x-rays deliver less radiation, they still can give 75 times more radiation than a chest x-ray. That’s especially worrisome to men and women of childbearing age, because x-rays and CT scans of the lower back can expose testicles and ovaries to radiation. Furthermore, the tests often reveal spinal abnormalities that could be completely unrelated to the pain. Those findings can cause needless worry and lead to unnecessary follow-up tests and procedures such as injections or sometimes even surgery.

When do imaging tests make sense?

It can be a good idea to get an imaging test right away if you have signs of severe or worsening nerve damage, or a serious underlying problem such as cancer or a spinal infection. “Red flags” that can alert your doctor that imaging may be worthwhile include:

  • A history of cancer.
  • Unexplained weight loss.
  • Fever.
  • Recent infection.
  • Loss of bowel or bladder control.
  • Abnormal reflexes, or loss of muscle power or feeling in the legs.

If none of these additional symptoms is present, you probably don’t need an imaging test. Your best approach would be to follow the self-care measures described at right. Back pain often recurs and it is typical for your symptoms to come and go. That doesn’t mean anything is seriously wrong, it is just the way most back pain behaves.

How should you treat lower back pain?

Your doctor can advise you on how best to treat your lower back pain. Most people get over back pain in a few weeks, and these simple steps might help:

Stay active

Resting in bed for more than a day or so can cause stiffness, weakness, depression, and slow recovery.

Apply heat

A heating pad, electric blanket, or warm bath or shower relaxes muscles.

Consider over-the-counter medicines

Good options include pain relievers such as acetaminophen (Tylenol and generic) or anti- inflammatory drugs such as ibuprofen (Advil and generic) and naproxen (Aleve and generic).

Sleep comfortably

Lying on your side with a pillow between your knees or lying on your back with a few pillows beneath your knees might help.

Talk with your doctor

If symptoms don’t improve after a few days, consider seeing a doctor to make sure that the problem doesn’t stem from a serious underlying health problem. If the pain is severe, ask about prescription pain relievers.

Chronic Kidney Disease: Making hard choices

Your kidneys remove waste and extra water from the blood in your body. This waste and water then leave your body as urine. Without the kidneys, the waste would keep building up and, over time, you would die.

When the kidneys are not healthy, they have a hard time removing waste from the blood. Chronic kidney disease moves slowly from early stages (stages 1 and 2), which usually have no symptoms, to advanced stages (stages 3, 4, and 5). Stage 5 is called “end-stage kidney disease.” This is because the kidneys can no longer be saved.

The best care can be hard to choose

Usually, people with chronic kidney disease also have other health problems. The most common are diabetes and high blood pressure. Anemia (low iron in the blood), bone disease, and heart disease are also common.

Because kidney disease can cause so many other problems, getting the right care can be complicated. You may need to see many specialists, and for many years. Your disease might get worse even if you are getting careful treatment. You may need dialysis or a kidney transplant when your disease has reached an advanced stage.
If you or a family member have chronic kidney disease, it may not be easy or clear how to choose among the many tests and treatments that are available. You may not even want or need some of them.

This brochure explains two treatments that are offered for chronic kidney disease. You, your family, and your doctor should carefully talk through the benefits and risks of each.

Anemia drugs

One important decision you may have to make is whether to treat anemia. Anemia is common in people with kidney disease.

Anemia is when you do not have enough red blood cells. Red blood cells carry oxygen to your body. Without enough red blood cells, your body does not get enough oxygen. You will likely feel tired and may have a hard time breathing.

Red blood cells contain hemoglobin. This is a protein with a lot of iron that gives your blood its red color. Your doctor learns if you have anemia and how serious it is by measuring your hemoglobin level.

If a blood test shows that you have anemia, you will need to decide if you should take drugs to help your body make new red blood cells. These drugs are called erythropoiesis-stimulating agents (ESAs).

ESAs are sometimes used to raise the number of red blood cells, even when a patient does not have severe anemia or symptoms. But research shows that the drugs do not help people with chronic kidney disease live longer. And when they are used aggressively, they can actually raise the risk of death by causing heart failure, heart attack, or stroke.

Bottom line:

You should consider an ESA only if you have symptoms of anemia, such as feeling tired or short of breath, and you also have a very low hemoglobin level. Very low is under 100g/l.

If you and your doctor decide to try an ESA, you should take the lowest dose that relieves your symptoms and keeps your hemoglobin level just high enough that you do not need blood transfusions. Tell your doctor all your symptoms and talk about how they will improve.

Deciding whether dialysis is right for you

Another important decision you may have to make is whether to have dialysis. This is something you may have to consider if your kidneys get close to failing.

Dialysis takes over some of the things your kidneys normally do, like removing waste and keeping a safe balance of water and salts in your blood. But dialysis is not a good idea for everyone with advanced kidney disease. Dialysis is hard on a person, and many people have to go a hemodialysis centre at least three days a week. Each treatment session lasts three to five hours, and common side effects of hemodialysis include headaches, nausea, and feeling tired. In surveys of older adults on long-term hemodialysis, over half of them say they wish they had not started the treatment. Many say they only chose hemodialysis because their doctors wanted them to.

In some cases, dialysis does not relieve your symptoms. It may not help you do your normal activities, stay independent, or live longer. That is especially true the older you are, and if you also have a heart disease or another condition that can shorten your life. In one study of more than 3,000 nursing home residents, more than half died within a year of starting dialysis. Of the people who survived, most felt a sudden drop in their ability to do routine tasks on their own. More information for patients about the options when your kidney fail (transplant, dialysis or conservative care) can be found at

Bottom line:

You should talk with your doctor, your family, and any other caregivers you have before you decide if long-term dialysis is the right choice for you. Ask your doctor to tell you all the benefits and risks of dialysis. Ask how well dialysis will manage your symptoms and how it will affect your lifestyle. And ask how your symptoms would be managed if you do not start dialysis.

How can you protect your kidneys?

There are things you can do to slow the progress of kidney disease and prevent complications. Take these steps:

Keep your blood pressure at a healthy level

Keep your blood pressure below 130/80 mm/Hg, or even lower if your doctor has told you that you have protein in your urine. The two best types of blood pressure drugs for protecting the kidneys are:

ACE inhibitors
  • ramipril (Altace and generic)
  • perindopril (Coversyl and generic)
  • enalapril (Vasotec and generic)
  • candesartan (Atacand)
  • losartan (Cozaar and generic)
Keep diabetes under control

If you already have diabetes, try to keep your long-term blood sugars under reasonable control. Discuss with your doctor.


Physical activity can help lower blood pressure, control diabetes, and prevent weight gain. Ask your doctor about physical activities that would be right for you.

Avoid certain drugs and supplements

Some drugs, vitamins, and herbs can harm your kidneys. Ask your doctor if anything you’re taking is unsafe.
Harmful drugs include certain:

  • Antibiotics
  • Antivirals
  • Pain relievers
  • Harmful supplements include those with:
  • Aristolochia (used for arthritis and edema)
  • Wild ginger
Do not smoke

Smoking can double how fast your disease progresses to end-stage kidney failure. If you smoke, talk to your doctor about programs to help you quit.

Pain medicines: What to do if you have heart problems or kidney disease:

When people have pain, they often take pain medicines called NSAIDs (non-steroidal anti-inflammatory drugs). These include:

  • Advil and Motrin (generic and store-brand ibuprofen). Ibuprofen is also in other over-the-counter drugs, such as cold medicines.
  • Aleve (generic and store-brand naproxen).
  • Celebrex (generic celecoxib).

NSAIDs help ease pain and inflammation. But if you have high blood pressure, heart failure, or kidney disease, you should not take an NSAID. And you should not take any drugs that have ibuprofen or another NSAID in them. Here’s why:

NSAIDs are bad for your blood pressure

NSAIDs can cause high blood pressure. And if you have high blood pressure, they can make it worse. This increases your chances of having a heart attack or a stroke.

NSAIDs can also keep some blood pressure drugs from working right. NSAIDs can interfere with:

  • Diuretics, or water pills, such as apo-Hydro (generic hydrochlorthiazide). Diuretics remove excess water from the blood vessels.
  • ACE inhibitors, such as Altace and Coversyl (generic ramipril and perindopril). ACE inhibitors are drugs that relax the blood vessels.
  • ARBs such as Cozaar (generic losartan). ARBs are another group of drugs that relax the blood vessels.

NSAIDs are bad for your heart and kidneys

Long-term use of NSAIDs can make your body hold onto fluid. This can worsen the symptoms of heart failure, such as shortness of breath, swollen ankles, and a rapid or irregular heartbeat. NSAIDs can also keep the kidneys from working well. This makes taking NSAIDs risky for people who already have kidney disease.

Which painkillers can you use if you have heart or kidney disease?

There is no simple answer. The best painkiller to use depends on your health problems. It also depends on any other drugs you take. Be sure to tell your doctor about any prescription drugs, over-the-counter drugs, or herbal medicines you take.

Over-the-counter Tylenol (generic acetaminophen) is often the best choice for people with high blood pressure, heart failure, or kidney problems.

  • However, high doses of Tylenol can damage the liver, so take the lowest dose you can to get enough pain relief.
  • Never take more than 4,000 milligrams (mg) a day. That’s equal to twelve 325 mg pills.

Managing pain without taking drugs

Non-drug treatments, such as yoga or massage, can often reduce or even replace the need for drugs. Here are some things you can try, depending on your kind of pain:

Back pain

Stay physically active. Walking is a good choice. Acupuncture, massage, physical therapy, and yoga can help reduce pain, too. And care from a chiropractor may help.


Cut back on alcohol and avoid foods that trigger your headaches. This may help relieve pain. Exercise can help reduce stress that causes headaches. So can meditation, deep breathing, and other forms of relaxation therapy.


Do low-impact exercise, such as walking, biking, and yoga. This can help ease pain and stiffness. Avoid high-impact activities, such as running or tennis. They can make your symptoms worse.


Get regular exercise to help reduce pain and give you more energy. Tai chi— a form of exercise involving slow, gentle movements combined with deep breathing—is a good choice. Meditation can help with pain. So can a type of counseling called cognitive behavioral therapy.