Eight Ways General Internists Can Practice High-Value, Low-Carbon Care: The Canadian Society of Internal Medicine’s Climate Conscious Choosing Wisely Canada Recommendations

Introduction

Climate change is the twenty-first century’s biggest threat to human health. Paradoxically, North American healthcare delivery is carbon intensive. Addressing low-value interventions stands to reduce healthcare’s carbon footprint. In this position paper, we describe eight new climate focused Canadian Society of Internal Medicine (CSIM)—Choosing Wisely Canada (CWC) recommendations to help internists stop or reduce tests, treatments, and procedures that do not benefit patients and harm the environment.

Methods

The CSIM planetary health task force drafted 14 potential recommendations. This list was refined to eight final recommendations based on feedback from the CSIM membership via an online survey, an online seminar, and expert review by the CWC planetary health panel.

Recommendations

The eight recommendations are as follows: (1) Do not prescribe intravenous antibiotics for patients who can safely be treated with an oral option; (2) do not prescribe heparin or low molecular weight heparin when oral options are effective, preferred by the patient and felt to be safe by the prescriber; (3) do not prescribe greenhouse gas-intensive metered-dose inhalers where a greener alternative with comparable efficacy is available, technique is adequate, and patient preference has been considered; (4) do not recommend/order investigations or interventions before discussing patients’ expected trajectory of health and life expectancy, and exploring their goals of care; (5) do not continue medications without confirming clinical indications, particularly for sedative medications, proton pump inhibitors, and inhalers; (6) do not order daily blood tests on hospitalized patients if it will not change management; (7) do not use non-sterile disposable gloves when hand hygiene is sufficient; (8) do not book in-person follow-up appointments when a virtual visit is clinically appropriate and is preferred by the patient.

Conclusion

Using a consensus process, the CSIM recommends eight evidenced-based practices that can feasibly be adopted by general internists to reduce the carbon footprint associated with low-value clinical care.