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Letters to the Editor

Choosing Wisely Canada

Integrating Stewardship in Medical Education

Leon-Carlyle, Marisa; Srivastava, Raman; Levinson, Wendy MD

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doi: 10.1097/ACM.0000000000000932
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To the Editor:

We were delighted to read about the success of the American Choosing Wisely campaign.1 Choosing Wisely Canada was launched on April 2, 2014 and similarly targets physicians and patients. As medicine recognizes the importance of resource stewardship in practice, there has been a congruent demand for the topic to be explicitly and implicitly included in medical curricula.2–4 Teaching students stewardship from the beginning of their education primes their medical knowledge and clinical thinking to ensure they are equipped to resist learning current wasteful medical practices.

Most medical curricula do not celebrate restraint.4 Instead, medical education rewards thoroughness, curiosity, and searching for “zebras.” When students are asked to work up a patient, credit is awarded for naming tests of tangential clinical benefit. Associated costs and harms—such as increased anxiety, longer wait times, and unnecessary complications—are rarely discussed. Students learn to value overuse, the very problem stewardship aims to reduce.

The underlying intention is logical—developing broad, critical thinking skills is vital for migrating students from book to bedside. Students must learn to develop differential diagnoses and investigate beyond typical presentations. We posit that teaching stewardship principles early contextualizes these lessons by bounding clinical searches with evidence-based knowledge.

This thinking underlies Choosing Wisely Canada’s targeting of medical education. At the University of Toronto, stewardship content was increased by making small, but significant changes to existing cur ricula. We analyzed the undergraduate curricula, cataloged our experiences, and determined where stewardship naturally fit in existing education. We developed a spiral curriculum with distinct stew ardship learning objectives for each medical year. We then collaborated with administrators and mapped stewardship lessons where relevant. In the first year, stewardship is integrated in various lectures and seminars. Second-year lecturers are e-mailed relevant Choosing Wisely recommendations. Clerkship students attend stewardship seminars and learn value-based decision making in reframed internal medicine lessons.

Similar to Wolfson and colleagues’ findings, the message of stewardship has strongly resonated with our faculty and students. The majority of lecturers have responded positively to our requests. Most importantly, student peers have begun to question low-value clinical decisions and weigh the risks and benefits of previously unquestioned interventions. Conversations have shifted from “What tests should we order?” to “What do we need to know?”

To become a norm in medical practice, resource stewardship must be taught early in education. Updating curricula does not necessitate extra hours, and we hope our experiences can inspire similar curricula elsewhere.

Marisa Leon-Carlyle

MD candidate, Faculty of Medicine, University of Toronto, and medical student researcher, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada;

Raman Srivastava

MD candidate, Faculty of Medicine, University of Toronto, and medical student researcher, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.

Wendy Levinson, MD

Chair, Choosing Wisely Canada and Choosing Wisely International, professor, Department of Medicine, University of Toronto, and scientist, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.


1. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: A short history of the choosing wisely campaign. Acad Med. 2014;89:990–995
2. Cooke M. Cost consciousness in patient care—what is medical education’s responsibility? N Engl J Med. 2010;362:1253–1255
3. Weinberger SE. Providing high-value, cost-conscious care: A critical seventh general competency for physicians. Ann Intern Med. 2011;155:386–388
4. Detsky AS, Verma AA. A new model for medical education: Celebrating restraint. JAMA. 2012;308:1329–1330
© 2015 by the Association of American Medical Colleges