the lists of "five things physicians and patients should question" developed by specialty societies. reception dr. danielle martin's three ideas to improve canadian healthcare the response to choosing wisely canada has been positive, with clinicians across the country expressing support for the campaign and highlighting the need for more resource stewardship. danielle martin, family physician and vice-president medical affairs and health systems solutions at women's college hospital, lists choosing wisely canada as one of three major ideas to improve canadian healthcare, highlighting that "choosing wisely canada is not a rationing or cost-cutting exercising. it is about reorganizing healthcare services so we only do things for people that truly benefit their health." chris simpson, past president of the canadian medical association, professor of medicine and chief of cardiology at queen's university, kingston, notes "physicians are really embracing the principles behind choosing wisely. it's all about the right thing to do for patients and avoiding the harm that can come from unnecessary testing. let's do more of what works and…and less of what is done 'just in case'. society expects us to lead the way, and the physicians of canada intend to do just that". rick glazier, senior scientist in primary care and population health at the institute for clinical evaluative sciences in toronto, highlights two aspects of the campaign that he believes are unique and have great potential. "the first", he states, "is that it's targeted to the public, and the second is that it's driven not only by scientists and medical journals, but by the professional organizations themselves. for radiologists to come forward and say you shouldn't order radiology tests under these circumstances, this is unprecedented". the final report of the advisory panel on healthcare innovation to rona ambrose, minister of health (canada), saluted choosing wisely canada "as an innovative physician-led and patient-centered approach that has the potential to shift healthcare away from a culture of consumption to a focus on appropriateness and quality of care". furthermore, the panel urged "governments to support the implementation of in all jurisdictions and to carefully evaluate its impact". in addition to endorsements from eminent physician leaders and professional organizations, choosing wisely canada received positive media coverage in national media sources, including the globe and mail, the canadian broadcasting corporation, and the toronto star, which heralded choosing wisely canada as one of the top medical breakthroughs of the year. on the other hand, early criticism of choosing wisely in the united states highlighted that some specialty recommendations addressed overuse of resources by primary care specialties, instead of addressing unnecessary tests and procedures conducted by their own specialty colleagues. choosing wisely canada responded to such criticisms by setting guidelines for its list development, which required recommendations put forward by specialty societies to pertain specifically to the specialty's scope of practice. many physician bloggers assert that most medical overuse is a result of practicing defensive medicine in an effort to avoid lawsuits. others recognize the noble goal of reducing overuse and harm, but lament that the lists are too simplistic and do not necessarily advance the identification of low-value care, but merely synthesize "agreed-upon, well-established practices". a critique of the choosing wisely campaign published in the journal of the american medical association by clement and charlton highlights a number of shortcomings in the overall movement. while the critique commends the campaign for succeeding in its goal of promoting conversations about low-value care, the authors of the critique believed that the process of list development were based on "quasi-systematic methods that focus on physician participation to increase support". the critique additionally called for increased evidence of the efficacy of the "top five" lists in terms of reduction in wasteful practices. clement and charlton furthermore warn of "top five list burnout", noting that when faced with multiple guidelines on a single topic, physicians become confused regarding which protocol to follow. in spite of these criticisms, clement and charlton "strongly believe in the global spirit behind the choosing wisely campaigns and movement" and "advocate that the priority in 2015 should be thoughtful implementation and rigorous evaluation of existing top five lists". impact choosing wisely canada has identified a multifaceted evaluation approach to measure its impact, which includes: physician attitudes and self-reported experience (through physician surveys) patient receptiveness to campaign messages reduction in ordering of low-value tests and procedures implementation in medical education evaluation of campaign impact on patient education and receptiveness included a randomized control trial entitled empower (eliminating medications through patient ownership of end results), led by cara tannenbaum, geriatrician and professor in the faculties of medicine and pharmacy at the université de montréal. the trial recruited more than 300 patients aged 65–95 years in the greater montréal area who were long term users of benzodiazepines. approximately half the patients were exposed to educational intervention, which included choosing wisely recommendations around excessive benzodiazepine therapy. the patients were then followed for 6 months. the study found that 62% of patients who received the intervention initiated conversation regarding benzodiazepine therapy discontinuation with physicians and/or pharmacists. after six months, 27% of the intervention group had stopped taking benzodiazepines, compared with 5% of the patients who did not receive the educational intervention. the impact of choosing wisely canada on test ordering and utilization was studied at the north york general hospital in the greater toronto area, one of the early adopters of the campaign. a multi-faceted campaign was implemented particularly in the hospital emergency department in june, 2014. test utilization in the emergency department was analyzed between september 15 and november 21, 2014, and compared to the same 10-week period in 2013 to account for any seasonal variances. the study found a 41% decline in the number of laboratory tests ordered pre- and post- cwc program implementation, without any observable change in outcomes. a preliminary cost analysis revealed annual departmental savings of approximately $215,000 while maintaining the same quality of care. a quality improvement initiative based on cwc principles was launched under the supervision of danielle martin at the women's college hospital (wch) in toronto. the american thyroid association and choosing wisely canada recommends testing only thyroid stimulating hormone (tsh) levels rather than testing both tsh and free thyroid hormones (such as t4) for assessment of suspected hypothyroidism, since majority of patients with hypothyroidism will present with abnormal tsh levels. a baseline audit at women's college hospital revealed that 60% of all free thyroid hormones tests were performed in patients who had normal tsh levels, amounting to approximately $50,000 annually in additional laboratory testing expenditure. a "reflex t4" approach was implemented at wch, wherein free t4 tests would not be conducted unless tsh levels are abnormal, or if there are clinical indications of situations when measurement of free thyroid hormones would be necessary. when it is found that tsh levels are abnormal, free t4 levels would then be automatically measured. in addition to reducing inappropriate thyroid function testing, the impact of choosing wisely canada is felt through numerous physician and patient awareness campaigns conducted at the hospital. medical education efforts of cwc are currently centered at the university of toronto, where choosing wisely principles are integrated into the undergraduate and postgraduate medical curricula through problem-based learning seminars, lectures, resident research projects and academic half days. following the example of choosing wisely in the united states and choosing wisely canada, health leaders from australia, austria, brazil, denmark, england, france, germany, india, israel, italy, japan, netherlands, new zealand, south korea, switzerland, and wales have committed to initiating similar campaigns revolving around medical stewardship and low-value care in their respective countries. italy has integrated the principles of choosing wisely in a campaign called "doing more does not mean doing better", and the netherlands has launched "choosing wisely netherlands", both contributing to a growing international choosing wisely movement partners choosing wisely canada is supported by the university of toronto, unity health toronto (toronto) and the canadian medical association. it receives funding from the canadian medical association, along with grants from federal, provincial and territorial ministries of health, and other partner organizations and agencies. the specialty societies participating in the campaign include: association of medical microbiology and infectious disease canada canadian academy of child and adolescent psychiatry canadian academy of geriatric psychiatry canadian academy of sport and exercise medicine canadian anesthesiologists society canadian association for the study of the liver canadian association of emergency physicians canadian association of gastroenterology canadian association of general surgeons canadian association of medical oncologists canadian association of nuclear medicine canadian association of pediatric surgeons canadian association of pathologists canadian association of radiation oncology canadian association of radiologists canadian cardiovascular society canadian critical care society canadian dermatology association canadian geriatrics society canadian headache society canadian hematology society canadian medical association forum on general and family practice issues canadian neurological society canadian nurses association canadian orthopaedic association canadian paediatric society canadian pain society canadian pharmacists association canadian psychiatric association canadian rheumatology association canadian society for surgical oncology canadian society for transfusion medicine canadian society for vascular surgery canadian society of allergy and clinical immunology canadian society of clinical chemists canadian society of echocardiography canadian society of hospital medicine canadian society of internal medicine canadian society of nephrology canadian society of palliative care physicians canadian society of respiratory therapists canadian society of endocrinology and metabolism canadian spine society canadian thoracic society canadian urological association college of family physicians of canada occupational medicine specialists of canada society of obstetricians and gynaecologists of canada trauma association of canada the campaign is also endorsed by all the canadian provincial and territorial medical associations: alberta medical association doctors of bc doctors manitoba doctors nova scotia medical society of pei new brunswick medical society newfoundland and labrador medical association ontario medical association quebec medical association saskatchewan medical association the national medical organizations endorsing cwc include: canadian association of professors of medicine canadian partnership against cancer royal college of physicians and surgeons of canada choosing wisely canada has also partnered with a number of patient and community groups which include: canadian arthritis patient alliance canadian association of retired teachers canadian association of social workers consumer reports health gastrointestinal society national association of federal retirees patients canada