Choosing Wisely Canada (CWC) is a Canadian-based health education campaign launched on April 2, 2014 under the leadership of Wendy Levinson, in partnership with the Canadian Medical Association, and based at Unity Health Toronto and the University of Toronto.Levinson W, Huynh T. Engaging clinicians and patients in conversations about unnecessary tests and procedures: Choosing Wisely Canada. CMAJ. 2014 Mar 18;186(5):325-6. The campaign aims to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to assist physicians and patients in making informed and effective choices to ensure high quality care.Canadian Medical Association [website]. Choosing Wisely Canada.Ottawa, ON: Canadian Medical Association; 2014. Available from:www.cma.ca/En/Pages/choosing-wisely-canada.aspx.
The campaign is based on the notion that unnecessary tests, treatments, and procedures often do more harm than good, resulting in poor clinical outcomes and significant waste in the Canadian healthcare system.Horwitz LI, Masica AL, Auerbach AD. Introducing Choosing Wisely®: Next steps in improving healthcare value. J Hosp Med. 2015 Mar;10(3):187-9 These unnecessary tests and procedures take away from care by potentially exposing patients to harm, leading to more testing to investigate false positive tests, and contributing to unnecessary anxiety and avoidable costs for patients. Choosing Wisely Canada aims to encourage and empower physicians to assimilate, evaluate, and implement the ever-increasing amount of evidence on current best practice. The campaign also supports the equally important role of patient education and the need to dispel the false notion that "more care is better care".
Central to the campaign are lists of "Things Clinicians and Patients Should Question" developed by more than eighty Canadian specialty societies. These lists are intended to encourage clinicians to adopt a "think twice" attitude to avoid unnecessary and potentially harmful tests and procedures, and to foster discussions between patients and clinicians about inappropriate care. The campaign also uses patient-friendly education materials to complement these lists, as well as teaches medical trainees about resource stewardship. As of November 1, 2025, 600 clinician recommendation have been released.
Choosing Wisely Canada leads an international community, made up of nations who are implementing similar programs in their respective countries. At present, this community includes representation from Australia, Austria, Brazil, Denmark, France, Germany, India, Israel, Italy, Japan, Netherlands, New Zealand, South Korea, Switzerland, United Kingdom, and United States.
Motivation
Choosing Wisely Canada stems from worldwide concern around providing unnecessary treatment when the risk of harm exceeds its potential benefit ("medical overuse").Morgan DJ, Wright SM, Dhruva S. Update on medical overuse. JAMA Intern Med. 2015 Jan;175(1):120-4 A number of studies have highlighted the prevalence of medical overuse in Canada, which include findings that approximately 50% of prescriptions for respiratory infections in Saskatchewan are inappropriate,Wang, E. E., Einarson, T. R., Kellner, J. D., & Conly, J. M. (1999). Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clinical infectious diseases, 29(1), 155-160. 28% of lumbar spine MRIs in Alberta and Ontario are unnecessary,Emery, D. J., Shojania, K. G., Forster, A. J., Mojaverian, N., & Feasby, T. E. (2013). Overuse of magnetic resonance imaging. JAMA Internal Medicine,173(9), 823-825. and 28% of bone mineral density scans are inappropriate.Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary. CMAJ. 2010 Nov 23;182(17):1864-73. These unnecessary invasive procedures and low-value care are major causes of preventable harm and increased waste of medical resources.Berwick, D. M., & Hackbarth, A. D. (2012). Eliminating waste in US health care. Jama, 307(14), 1513-1516. Medical overuse has been associated with decreased patient satisfaction and poor clinical outcomes, including higher mortality.Fisher, E. S., Wennberg, D. E., Stukel, T. A., Gottlieb, D. J., Lucas, F. L., & Pinder, E. L. (2003). The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Annals of Internal Medicine, 138(4), 273-287. A systematic survey of patients in seven countries revealed that 10–20% of patients believed that their physicians had provided treatment of little or no value in the past two years.Schoen, C., Osborn, R., Doty, M. M., Bishop, M., Peugh, J., & Murukutla, N. (2007). Toward higher-performance health systems: adults' health care experiences in seven countries, 2007. Health Affairs, 26(6), w717-w734. Further studies highlighted the financial strain of medical overuse, such as the analysis conducted by the Institute of Medicine, which found that up to 30% of American health care spending is on unnecessary tests and procedures.Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014. Epub ahead of print. In 2017, a joint report between Choosing Wisely Canada and the Canadian Institute for Health Information found up to 30% of tests and treatments were unnecessary based on eight campaign recommendations. Unnecessary Care in Canada | CIHI In light of these concerns, Choosing Wisely Canada hopes to optimize value, reduce waste and improve patient outcomes by promoting patient-physician conversations about low-value care.
History
Choosing Wisely Canada is modeled after the Choosing Wisely campaign launched by the ABIM Foundation of the American Board of Internal Medicine in the United States in 2012.Harvey EJ. Choosing wisely (and carefully) Canada. Can J Surg. 2014 Jun;57(3):149, 151. Wendy Levinson, a Canadian physician and previous chair of the ABIM Board of Directors, was involved in launching the Choosing Wisely campaign in the United States.Smith, C. D., & Levinson, W. S. (2015). A Commitment to High-Value Care Education From the Internal Medicine Community. Annals of Internal Medicine,162(9), 639-640 After its successful launch, she decided to bring the movement to Canada and partnered with the Canadian Medical Association and the University of Toronto to launch Choosing Wisely Canada on April 2, 2014. In the first wave of the campaign, nine national medical specialty societies released evidence-based lists of 41 tests, treatments and procedures that provided no benefit or potentially caused harm to patients.
Under the leadership of Wendy Levinson and the Canadian Medical Association, Choosing Wisely Canada initially gained momentum in Ontario and subsequently became a national movement.Gupta S, Detsky AS. Development of Choosing Wisely Recommendations for an Inpatient Internal Medicine Service. JAMA Intern Med. 2015 Feb 23. The second and third waves of physician recommendation lists and patient education materials were launched on October 29, 2014, and June 2, 2015, respectively.Vogel, L. More Hospitals Choose Wisely.CMAJ June 8, 2015 cmaj.109-5078 As of June 2, 2015, more than 80 Canadian medical specialty societies are engaged and at various stages of recommendations development. In total, 400 clinician recommendations and 39 lay language patient educational materials have been released in the three waves from 2014–2015.
Campaign
Choosing Wisely Canada has adopted a multi-faceted campaign approach, engaging clinicians, patients, and medical trainees at all levels. The campaign has partnered with more than 80 Canadian medical specialty societies to develop evidence-supported lists of "Things Clinicians and Patients Should Question", hoping to promote conversation about inappropriate care. The underlying premise is that clinicians must lead such conversations, since they determine the appropriate or inappropriate use of resources. CWC has also developed complementary patient-friendly education materials, and has begun to embed lessons focusing on resource stewardship in undergraduate and postgraduate medical curricula. In order to unify grassroots projects occurring across Canada to implement clinician recommendations, CWC additionally developed the Early Adopters Collaborative, which serves as a "learning platform for sharing knowledge, tools and experiences among participating organizations".Holton, E. Choosing Wisely: Tackling Unnecessary X-rays in the ICUS. St. Michael's Hospital Newsroom. Available at: http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2015/20150624_hn
Clinician Recommendations Lists
At the core of the campaign are lists of "Things Clinicians and Patients Should Question" developed by national specialty societies representing a broad spectrum of clinicians. These lists contain tests, treatments or procedures commonly used in their specialty, but which are not supported by evidence, and/or could expose patients to unnecessary harm.Hurley, R. (2014). Can doctors reduce harmful medical overuse worldwide?. BMJ, 349, g4289.
List items recommend practices to be avoided and typically begin with the word "Don't" or "Avoid"; for example, one of the recommendations released in the first wave of the campaign was Don't order screening chest X-rays and ECGs for asymptomatic or low risk outpatients.Canadian Association of Radiologists. Medical imaging primer with a focus on x-ray usage and safety [Internet]. [Cited 2014 Feb 15]. Available from: http://www.car.ca/uploads/standards%20guidelines/20130128_en_guide_radiation_primer.pdf . National specialty societies are free to determine the process for generating their lists, as long as they are done in accordance with the following principles:
The development process is thoroughly documented and publicly available Each recommendation is within the specialty's scope of practice (and not pertaining to other specialties such as family medicine) Tests, treatments or procedures included are those that (a) are frequently used, and, (b) may expose patients to harm or stress. Each recommendation is supported by evidence
Choosing Wisely Canada recommendations are not intended to be used to establish payment and coverage decisions. Rather, the lists are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, Choosing Wisely Canada recommends that its materials be used as guidelines for clinicians and patients to determine an appropriate treatment plan together.Baron RJ, Wolfson D. Advancing medical professionalism and the choosing wisely campaign. JAMA Intern Med. 2015 Mar 1;175(3):464-5.
Patient education
In order to encourage patients to initiate conversations about unnecessary care, Choosing Wisely Canada uses patient-friendly materials with lay language to complement the lists of "Five Things Clinicians and Patients Should Question". These patient educational materials are meant to inform patients about the tests, treatments and procedures used within various medical specialties, when they may or may not be necessary, and what patients can do to improve their overall health.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 Jul;89(7):990-5. For example, one of the patient educational materials released on June 2, 2015, addressed concerns regarding the amount of bed rest required to treat lower back pain, advising that staying in bed longer than 48 hours will not help, and in fact, may actually delay recovery.Recommendations target overuse of unnecessary medical procedures. BCMJ, Vol. 57, No. 6, July, August 2015, page(s) 237–238.