Thursday, September 1, 2011
Whittling costs in white coats
At the beginning of last week, I was excited to be invited to take part in the American Board of Internal Medicine Foundation's Summer Forum, where the who's who in medicine convened to discuss how to create a sustainable health care system, where costs are controlled and quality of care is preserved. We heard some bold visions and ideas, many of which were focused on badly needed policy levers or system redesign.
However, as I ended my week on Sunday with investing the University of Chicago Pritzker School of Medicine's new medical student class with their white coats, I was wondering how we can teach and empower individual trainees to do their part. As our speaker highlighted so eloquently, the most powerful thing about the white coat is what and who is in it, and also the learning that takes place in it. So, in that vein, here are some thoughts for what students and residents can do.
(Click on "More" below to continue reading.)
Read up on the topic
Here are some excellent resources I heard about at the meeting:
Physician Stewardship of Health Care in an Era of Finite Resources, a recent article in the Journal of the American Medical Association by Drs. Chris Cassel and David Reuben regarding the various levels of stewardship.
Personal Reflections on the High Cost of American Medical Care, a recent article in Archives of Internal Medicine by Dr. Steven Schroeder.
The Pricing of U.S. Hospital Services: Chaos Behind a Veil of Secrecy, a classic by noted economist Uwe Reinhardt.
"Less is More Series, a great resource in Archives of Internal Medicine edited by Rosemary Gibson and others.
Listen to the patient
Of course, this sounds simple, but the truth is that more times than not, the answer is in the patient history. With duty hours and workload, taking a detailed history sometimes takes a backseat to reviewing the electronic iPatient.
One approach is to start with two open questions: (1) Tell me about yourself; and (2) What are your health care goals? Often, the key is to try to understand the baseline. I once took care of an older patient who had abdominal pain and had received over 40 abdominal CTs over the past several years. When we were able to gather more information from the patient and her family, it turns out that she has had bad abdominal pain for over 30 years that would come and go! By working this information into her discharge summary and plugging her into primary care, our hope was to have her avoid future costly and harmful workups. As I've mentioned before, students often have more time with patients than residents or attendings and can often take the most helpful and detailed history!
Learn the physical exam
Often times, we rely on tests since we do not trust our physical exams. It is too easy to get an echo when you are wondering if you are truly hearing a murmur. The lore here is that you need to listen to a lot of normals to be able to detect the abnormal. Because of this, when I am on service, I usually invite the third year student to examine every patient with me so they can see a lot of exams. Usually by the end, they are more confident in their ability to detect crackles or murmurs.
As stated by our white coat speaker, the stethoscope is indeed a powerful tool. Interestingly, with the infectious increase in global health experiences among medical students and residents, working in resource poor settings requires ingenuity and reliance on the lowest technologically feasible solution. Closer to home, volunteering in a free clinic is likely to provide one with the same experiences.
Don't just check boxes. Ask why the test is indicated
Trainees can ask the difficult question, why are we ordering this test or medication? Is it indicated? An even better question to research is whether there is a cheaper (we can't shy away from using that word anymore) alternative that would provide the same information?
For example, before every pulmonary embolism protocol CT or Doppler to rule out deep venous thrombosis, I always ask my team to calculate the Wells score so we understand if the test is indicated and what our pretest probability is. In addition, every study has a downside, whether it be hospital-acquired anemia from phlebotomy or incidentalomas and pseudodisease from excessive imaging. It is easy to check boxes, it is harder to question why you are checking them.
Try to find out how much the test costs
While the answer is elusive, the goal is to start the conversation in your own backyard. There are anecdotal reports of residents going back over 10 years who have tried to work with their hospital billing departments to find out how much things cost. Moreover, greater knowledge of costs will change practice patterns as we've discussed before.
One impressive thing about the ABIM Foundation Forum was the representation of patient advocacy groups who were willing to partner with physicians and physician groups to reduce the costs of care. While the image that may immediately come to mind most is of a patient coming in to request a test that is not indicated, engaged and informed patients expressed the desire to work together and that less is more. In some communities, there is a lot of distrust of the medical care system and these conversations have to start one patient at a time.
Unfortunately, whittling health care costs is not as easy as teaching trainees. As long as our systems and the faculty within them promote costly workarounds such as misrepresenting tests as urgent to expedite them, ordering tests as fast as possible for fear of discharge delay, or wasteful lab testing, trainees will be reprimanded for not doing something. Therefore, to truly make change in our teaching hospitals, we must also ask that our faculty reach deep into their own white coats and find the courage to say "Don't just do something, stand there."
Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.
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