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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.

White Coat Ceremony by GLMS1 via Flickr and a Creative Commons licenseHowever, 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.

Counsel patients
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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, 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.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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