 Well it's really a pleasure to be here and I have to just comment on this absolutely glorious room that we're in which is just really breathtaking to see so it's a real treat to have the opportunity to stand here in this beautiful space and talk with you. And I also just want to start by saying I'm so impressed both by both the minister's talk and what we just heard about the alignment between what we're doing in Canada and in the United States in choosing wisely and many of the principles that we just heard about. So I think when you hear this you'll say Jesus really do intertwine. So I'm going to just share a little bit about our history. This is our logo which is supposed to be a dialogue bubble because conversation is at the heart of choosing wisely Canada and we have everything in English and French so we also say Choisier de la Swain which is quite nice because in French that means choose with care but also with caring. So we have both languages as we do this work. So everyone knows this and I won't belabor it but it's what you just heard that every country in the world you're not alone in Wales is struggling with the really remarkable pace of spending in health care and this is the percentage of gross domestic products spent in different countries on health care and as you can see the red at the top is the United States which is really having serious difficulties with their spending of almost 18% of gross domestic product on health care. The UK and Canada are below that but these curves worry everybody because it is what you heard unsustainable. So this is a slide that actually Don Burwick from the Institute for Health Care Improvement wrote published in JAMA and I understand that he's actually on the Bevan Commission and what it says is that he calls this the ledges of waste. So whatever the rate of increase in this gross domestic product being spent on health care the tragedy is that many of these things the things that we do don't add value and in fact he calls these like I said the wedges of waste and you can see that there's a wedge of waste around failure of the care delivery system that we don't do what we should to prevent illness so diabetics might not get early prevention there's failures of care coordination where the primary the family doctor GP doesn't know what happened in the emergency room just repeats the test so because we're not coordinated and I'm sure you have those problems with the silos here just as we do but there's a big wedge of waste that we're talking about today which is over treatment or over diagnosis and these are tests treatments and procedures that we do that as we just heard don't add value to patients they're not what's really needed and they just increase costs but they don't increase the quality of care for patients so this is the backdrop to the conversation that I think you're having in Wales and really every country is having can we get a handle on some of this by doing the right things for patients and avoid doing the wrong things that don't add value so what will we say of course as a physician I don't wake up in the morning and think gee let's go into the office and see if I can do a bunch of unnecessary things that don't add value for patients and patients do say all the time when we talk about this why do doctors order things that don't add value and I think there are multiple reasons often doctors say and we know in our surveys that 60 percent of doctors say that this is a main driver that patients want it my neighbor had an MRI she turned it you know she had a brain tumor I want that too so I make sure I'm okay so patients may come in with expectations which drive us to do tests that we know are not really needed I think we all are enamored with new technology um in our culture in medicine new fancy tests and treatments are sort of alluring both for doctors and patients and so we prefer to do these new technologies thinking they're better it's hard to um it's sometimes easier to do something than what might be perceived as doing nothing if patients go home and say their family member that family member says what happened you didn't get a prescription you didn't get a test they may feel that they didn't get care and it can be harder I think especially if you run away you're busy there are people in the waiting room to explain why you're not ordering that test or treatment than to just check off the box and do it so in fact in Canada there's a workshop called don't just do something stand there to try and get at this with family doctors we have expectations between primary care doctors or gps and consultants the referring doctor might expect that you've done an ultrasound before you send the patient to the urologist even though their urologist might not really need that and we so we refer we kind of do tests to meet the others needs we don't want to get sued this is a big driver in the US but it is in Canada too and I would expect here too especially in the emergency room doctors don't want to miss something they're melt they're in the United States in Canada we have a lot of financial misalignment so doctors might get paid more for doing more and I think the most important factor is that it's the way we learn to practice medicine when I see a patient with x I always order y and so we develop these habitual patterns of practice and they're hard to change we don't stop and think what could I stop doing so all of these things might contribute in it you know unconsciously to why we order things that maybe are not necessary or don't add value for patients so with that said choosing wisely is a campaign and the words here are quite important to us to help physicians and patients engage in conversations about unnecessary test treatments and procedures and help physicians and patients make smart and effective choices to ensure high quality care very much what we just heard that the prudent health care principles are it is about stimulating that conversation so in order to do that we began this campaign just a quick history in 2012 in the United States just April of 2012 so it's a very young campaign we started with medical societies in the way I'll describe in a minute and in the first instance we had nine medical societies participate there are now over 70 in the US and we launched in Canada just in April of 2014 so not very long ago also with nine societies and we have more than 30 participating now and a few minutes I'll tell you more about the growing international campaign so the approach of choosing wisely is to go to physicians it is a physician led campaign and ask physicians through their professional societies like the Canadian Cardiovascular Society the American College of Cardiology to develop a list and I'll show you in a minute of five things in their specialty for which there's excellent scientific evidence of overuse waste or harm so five things in their discipline the second component is a big patient education campaign with materials to try to change the understanding that that more right now patients often think more is better more tests more treatments and we know that that we have to educate the patients and public about that fourth is to coordinate big efforts with the media because we need to communicate this message broadly and to work with the stakeholder groups the hospitals the health regions in our country to try to implement these changes on a broader scale so here's what they look like every society and don't worry that you can't read it I want to show you the format and I'll show you a specific one every medical society working with us develop their list of five things physicians and patients should question and they all look like this and they start with the word don't so they look like don't do imaging for low back pain unless red flags are present and underneath it they have a little rationale of what's meant by red flags on the back of the page they have the references that go with item number one so what you can see is they're very simple they're very straightforward they all start with don't and they they are pretty easy for a physician in that field to understand what that goal is so all of the societies have created these list of five things but then what we that we worked in the states with consumer report a very respected independent organization and they created again I just want you to see the format patient pamphlets they're all online that that go with these recommendations so on all of them and this one is follows with the back pain you just saw they explain why imaging for low back pain doesn't help you get better faster and they explain that they can pose risks and what's quite good about these pamphlets is they not only explain direct risk like excess radiation but or drug reactions or whatever but they also explain to patients false positives because patients often don't understand that you get a test and it leads to another test and a biopsy and a complication and these brochures do that in very simple language they always include when you do need an imaging test because we're not we're not saying never do them we're saying you should do them in the right circumstance so they explain when you need them and they finally always have a panel about what you can do to help that problem how you should treat low back pain and they give you the more non you know the more non-invasive ways of helping your situation so we see these as useful for physicians for example to hand out to their patients so that in that conversation they can supplement by saying would you read this so these are in English and Spanish in the US and English and French in Canada but it's one thing to create the recommendations and it's completely different thing to put them into practice and I would tell you we're still in early stages about how to get this embedded but the funny thing about this slide is that the campaign manager for choosing wisely who I work very closely with obviously went to see a rheumatologist with his wife and in the rheumatologist's office he saw these pamphlets and he said to the rheumatologist do you mind if I take a picture in your office and so because we our goal is really to the hands of practicing physicians and there are a variety of ways that this is happening throughout North America I don't have time to go into all the detail but I'll give you an example so Cedar Sinai is a place is a hospital in LA that takes care of all the movie stars and it's notorious as being the most expensive place in the US which is hard to believe because it's all really expensive there and what they did is they took 150 of the choosing wisely recommendations and embedded it in their their physician computer order entry so if you go to order in this case a benzodiazepine in an older patient the American geriatric society's recommendation pops up and it tells you what that recommendation is and therefore you might be reminded of the choosing wisely recommendations of what not to do and we have some similar things developing in our systems where we have good electronic entry this is just one example I mean other places are giving physicians feedback on how they're performing in these don'ts compared to colleagues some centers in the US give them their exact information and everybody else's name and how they're doing so you can find out which colleague is doing better we love that competitive nature of doctors that thrive for quality improvement but obviously we're on a beginning of a journey to trying to get these embedded there are about over 300 recommendations in the US now we're about to launch our second set of recommendations of 16 new ones in Canada but the real rubber hits the road about getting them into practice so just a comment about medical education because I think it's very important we not neglect this because students have the same drivers as practicing doctors but they have a few others you might think about residents in our country and I bet in yours like to show that they're thorough that they've thought of every possible rare disease that the attending consultant could ask them about on rounds the next day and they've ruled them all out by a bunch of tests and there's a lot of drivers still in our medical education culture to do that they also lack feedback residents and I'd say many of us have no idea how we're doing compared to our colleagues on our ordering practices residents in our country do preemptive ordering by that I mean if I get the CT scan tonight even if I don't really need it then if I need it tomorrow I'll be able to get the patient out of the hospital a day earlier so let's just order it now and again it's the way they're taught so they see this role model they see their attending physician order the you know CIRM whatever test and they do it too so you might think for a moment about how you engage students and residents in North America I can tell you the students are very enthusiastically choosing wisely they see all the crazy things that we do or maybe unnecessary things that actually yesterday I met with two of your clinical fellows who talked a lot about all the ways they see in their clinical settings so just a moment about the international collaboration there were 12 countries including Wales that came to a meeting in Amsterdam just in June and many of them were developing their own versions of choosing wisely you can see choosing wisely Australia Italy actually calls it do more does not mean doing better it also calls it the slow medicine movement based on slow food Japan is involved the Netherlands is doing it Switzerland is evolving a program and I listed prudent healthcare as aligned with what what you're doing aligned with this so this just to say Wales is not alone in trying to figure this out other countries are too and just quite a number of places are finding the principles of choosing wisely which is really physician led all of the countries in the discussion in Amsterdam really agreed that this was key to helping this be successful because I know as a doctor I don't warm kindly to an outside force telling me how to practice medicine we kind of balk at that we see it as interfering in our practice but if our own colleagues in respective medical organizations like the Canadian cardiovascular society in my case the Canadian Society of General Internal Medicine say these are things we shouldn't be doing and if I see that my colleagues are practicing in accordance with that I want to do that too and so I think this physician led engaged physicians part of the prudent principles engagement is very important its patient focus that's also consistent with the prudent healthcare evidence-based multi professional I didn't talk about that much but we really are trying to make it nursing pharmacy therapists etc and as you can see it's completely transparent all of these are posted everywhere so that people can see them so obviously in the bottom of the inner circle we're working towards reducing unnecessary care harm a waste but we realize we have a lot of work to do to have physicians and patients aware educated and engage them in this co-production as you would call it we think that real work is in the shared decision making that happens between the doctors and patients in the room when they discuss what is best for me so I get the right care and I avoid things that may be unnecessary or be that harmful and that the healthcare system hospitals and regional health networks can align to help support the physician and patient in making those decisions because really in the end healthcare is practiced in that exam room between the doctor and the patient and so choosing wisely is really designed to have that conversation bring up these issues which beforehand I think have really been silent and not allowed us to change the culture of medicine so with that I'll stop I really am interested in the conversation here because there's so much we can learn from what you're doing in food and health care and perhaps so much using wisely will inform your conversation thank you