Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
February 17th, 2015
Priya Umapathi, M.D.
In an era of near-instantaneous transmission of data, where multi-billion dollar financial transactions are completed in the blink of an eye and where the worldwide web will answer any question in less than 0.19 seconds, communication during patient encounters remains a thorny issue.
One recent afternoon, I saw Mrs. D in the medicine clinic. She originally had a 9 am appointment to (among other things) check her INR. She misunderstood the need to have her blood drawn prior to the visit but was directed to have blood work done and to return to be seen in the afternoon. When she arrived, we chatted as I worked my way down a seemingly endless list of primary care to-do’s and focused problem assessments. Having reviewed and communicated the significance of pertinent lab work and imaging, reconciled and e-prescribed medications, counseled her on smoking cessation/weight loss/exercise/low-salt diet, and made appropriate referrals, I considered it a successful 45-minute visit (yet well over my allocated scheduled time). I hurriedly explained medication adjustments I had made, bid Mrs. D farewell, and raced to grab my next patient’s chart.
It was a busy clinic day, and we ended late. While walking back to the hospital, I saw Mrs. D in the clinic waiting area. My heart sank. She looked so tired. She said she was waiting for a ride home. The medical transportation she had set up to take her back was for the morning, and the company would not reschedule. She hated being a burden on her kids, but she had swallowed her pride to call her daughter to ask for a favor. Tears started flowing as she said she had been waiting for me to finish so we could talk. She had tried to pick up insulin at her pharmacy, but I had prescribed Novolog, and her insurance carrier would only cover Humalog unless they received physician pre-approval. She had stayed in the waiting room for longer than an hour, waiting for me, because she was scared to go home without insulin or to navigate our labyrinthine resident clinic phone system to reach me. It took less than 3 minutes for me to reach, and speak with, the pharmacist to release her insulin. Overall, her time spent for a follow-up medicine visit and prescription pick up? 6 hours and 3 minutes
Our medical students take semester-long courses on effective doctor–patient communication. In residency, we have formal and informal discussions centering on cultural competency, identifying disparities in health literacy, and answering as basic a question as “can your patient read?” But sometimes, despite our best intentions, the challenges in delivering patient care are not apparent. We race through gathering, assembling, and synthesizing all the information present in an electronic medical record that is bloated with myriad notes, evaluations, medications, images, and lab information. (Don’t get me wrong! I can’t count the number of times I have been grateful for an EMR, especially at 2 am, while trying in vain to decode a consultant’s cryptic scribble). But our need to parse this data to help synthesize our treatment plans is time-consuming. Certainly, it is useful to review a trusted colleague’s prior note about the patient in front of you, but no amount of searching the record provides knowledge of the patient’s family, finances, or access to transportation.
A question to consider: How many of your patients neglect their preventive and follow-up care because it might jeopardize their jobs? Do you know?
How do we navigate a bulky healthcare delivery system that includes charges from managed care organizations, HMOs, and private insurers and costs for the private payer and still provide patients with the care they require? The interplay between these components and the need for their symbiosis for healthcare delivery is too complicated for even the most robust EMR. Residents and patients in a busy primary care clinic can feel both overwhelmed and underserved. New (and not-so-new) physicians have a limited knowledge of the complicated system that regulates what care patients have access to and of how to facilitate efficient treatment in an environment centered on cost (not necessarily care). The challenge of keeping patients at the center in a rapidly evolving healthcare environment remains.
One of my wisest clinic preceptors always underlined two things: the need to prioritize problems and the power of good conversation. I would argue that ticking check boxes for every screening recommendation and medical item over the span of a few visits, instead of cramming them all into one encounter, is a far better use of time. Learning that your patient can’t make a screening colonoscopy appointment because he doesn’t have transportation is more efficient than referring him multiple times without ever addressing the real problem. Turning away from your computer and talking to your patient (and not just about his diseases) initially might feel far less productive, but a few carefully chosen questions in fact could be the single best way to ensure your patient’s health.
As healthcare professionals, we have to connect with and understand our patients. Only then can we be successful at treating them.
December 22nd, 2014
Priya Umapathi, M.D.
In the midst of the holiday season, nestled as we are between Thanksgiving and New Year’s, I find myself in a reflective frame of mind. December marks the end of the year, and it harkens new beginnings on the horizon — and I find myself transitioning to new phases of my training. Some readers might find this post to be very introspective, but I thought it apt given the recent completion of many fellowship matches, including my own.
My self-reflection began in earnest this past summer. The confluence of being a chief resident, taking the ABIM and applying for fellowship mandated a time-sensitive and earnest appraisal of my abilities, dedication, and professional and personal goals.Like many of my co-fellowship applicants, my choice of subspecialty was a field that resonated with me and had inspired me to commit much of the past 3 years of my life to get to this point. We probably have all asked ourselves why we chose a particular field and what attributes made us best suited to pursue specific fellowship training. These answers, and the efforts made to attain them, distill into a personal statement. Amidst the flurry of activities I undertook to be a competitive candidate, I was forced to pause, to think, and to remember. Taking stock of not only who I am, but also how I had come to this stage in my career. Revisiting the whos, whens, whats, and whys of a lifetime of choices and experiences that led me to the present was a welcome epiphany. The rapid pace of daily life and myriad items that require immediate action seldom offer an opportunity to experience the richness that comes from reflection. Although challenging, periods of transition offer us opportunities to reflect, to understand, and — most importantly — to make peace with ourselves.
As my fellowship interview season came to an end, our residency interview season had just begun. I have been fortunate to gain another perspective, now from the other side of the proverbial “desk”. I am honored to have a window into the lives of those walking the path I took just 4 years earlier. In interviewing applicants, I am able to trace their journeys among schools, jobs, and even continents. Learning about their struggles and hearing about their successes serves to remind me of my own journey and challenges on the road to residency. We have all been challenged and struggled in different ways, but we are bonded in our shared medical training experience. Perhaps, in this, there is that proverbial sense of professional identity that allows us to empathize and relate to each other. The interview process has allowed me to continue to grow and mature, and has provided me with a greater understanding of myself and my connection to my colleagues.
The lessons learned personally and by proxy have humbled me and strengthened me and made me more resolute — both in who I am and in what I hope to be. These reminders of past efforts, successes, and failures don’t dampen or deter current success; in many ways, they serve to accent the beauty of the present and mark our arrival point. This Thanksgiving, I have many things in my life to for which to BE thankful, and the opportunities to reflect during the past year have brought much warmth and richness my way. My New Year’s resolution is to take more time to reflect on the past. A little introspection goes a long way! Happy Holidays!
October 6th, 2014
Priya Umapathi, M.D.
Hello! I’m excited to have an opportunity to share my adventures, experiences, and opinions from chief year with you. Transitioning between life phases can be traumatic at times, but invariably bears great potential for exponential self–growth. This year, so far, has confirmed that there is indeed much growing to be done! We held a transition event for our house staff prior to the beginning of this academic year, which I affectionately dubbed “Metamorphosis” (I know, corny), to discuss some of the expectations, roles, and responsibilities associated with becoming a senior resident. The many themes of the night included incorporating enthusiasm, intellectual curiosity, and compassion into our daily lives to become more effective leaders. I watch my new senior residents draw on these attributes daily as they navigate their way through managing patients and teams independently. We face an ever-changing landscape of medicine with challenges in implementation of healthcare reform, the work hour debate on resident and patient outcomes, the financials of medical school costs relating to choices for specialties, and the rise of genetically personalized healthcare, to name a select few… The adage, “may you live in interesting times,” has never been more apt! My hope is that I will be able to incorporate themes from our Metamorphosis event into my year as chief and look forward to sharing insights with you about both my personal and professional growth.
October 6th, 2014
The editors and staff of NEJM Journal Watch welcome Dr. Priya Umapathi as our new Chief Resident blogger. Priya will be sharing her experiences as a teacher and mentor at Rutgers.
April 28th, 2014
Akhil Narang, M.D.
“Are you more or less cynical than when you started residency?” This was the question my Program Director asked our senior internal medicine residents at a recent dinner with Dr. Bob Wachter. If you aren’t familiar with Dr. Wachter, he is widely acclaimed as the “Father of Hospital Medicine” and a renowned champion of patient safety and quality. His blog, Wachter’s World, is chock full of insightful commentary on the American healthcare system, written with levitating optimism. In a time where criticism of doctors and hospitals (coupled with pessimism reflecting the country’s healthcare system) is trendy, Dr. Wachter’s breath of fresh air is welcoming. It got my Program Director thinking about cynicism in medicine and inspired this post.
The 30-odd residents, months shy of graduating, got an opportunity to answer whether they viewed themselves as more or less cynical than at the start of their residency training. Many of responses reflected increased cynicism toward “the healthcare system.” When pressed to explain further, many answers stemmed from the frustration they feel when taking care of patients: difficulty in establishing primary care follow-up for the uninsured, inability to get antibiotics covered by insurance, administrative red tape of setting up home oxygen therapy, and even the cumbersome process of obtaining outside hospital records. It was refreshing, however, to hear residents qualify their cynicism. More often than not, residents did not single out cynicism toward patients as much as they did toward the system. If we are to continue producing generations of passionate and dedicated physicians who don’t burn out, we need to start addressing ways to deal with cynicism.
Short of nationwide reform, hospitals and residency programs can play a part in helping to shape (arguably) the most pliable time in a young physician’s career. While it’s certainly character building to be able to successfully navigate filling out nursing home transfer forms, finding a means to get a patient’s INR checked, making follow-up appointments, and calling insurance companies to plead for antibiotic approval, this type of work should not dominate the daily cycle of residency. There is little doubt that “scut work” helps us better understand the bureaucracy and red tape associated with our healthcare system, but it also unequivocally takes away from a plethora of formal educational opportunities and it contributes to violations of strict duty-hour regulations.
In speaking to my colleagues around the county, I have found that hospitals and residency programs provide variable support to their housestaff: some of the best programs offer dedicated resident assistants (typically PAs) and streamlined workflows for discharging patients (multidisciplinary rounds, discharge planners to schedule appointments). Residents who were the least cynical in my unscientific polling were those who had the most resources at their disposal. I wonder if, down the line, the less cynical residents become less cynical fellows and subsequently less cynical attendings. I wonder if these physicians experience less burn out than their colleagues whose training programs do not equip them to navigate the healthcare maze.
Recognizing that all hospitals and programs are not created equal and that perks such as PAs or discharge coordinators are luxuries that many hospitals aren’t in a position to provide, addressing the larger issue of cynicism in medicine is important. A certain degree of cynicism is healthy but when cynicism borders on indifference or complacency, we’re in trouble. To effectively curtail cynicism directed at the “system,” hospital leadership needs to engage their residents. For many hospitals, residents provide the greatest amount of hands-on patient care. Residents are often the first and last providers that patients encounter during hospitalizations. Every hospital recognizes the importance of quality improvement and creating lean workflows; resident input and feedback should be solicited at every step of the way. Concerted efforts to address issues that plague residents (whether it be better social work support or a lack of computers) should be taken seriously.
Residents need to feel empowered by their programs and hospitals to make changes. Whether those changes are major or minor, a collaborative effort between housestaff and hospitals will inevitably be well received. Unilateral decision-making (especially if controversial) can lead to significant resentment and to worsening cynicism. I have no delusions that once residents and fellows finishing their training, challenges in their practice environments (academics, private practice, or industry) certainly can augment cynicism. Nonetheless, if the formative years of one’s training are optimized, scores of physicians might enter their post-training careers with a less cynical mindset.
So now I ask you to reflect on your experiences. Are you more or less cynical than when you started your residency training? If you’re more cynical, why and how much of this was a result of modifiable factors in your training program?
April 5th, 2014
Paul Bergl, M.D.
In my transition from pure learner (i.e., the med student role) to teacher-learner (i.e., the attending), I’ve actually found myself focusing more on the learner than the teacher part of my dual existence. Strong learning seems to be requisite to strong teaching, and I am realizing that succeeding on the next level requires some extra meta-cognition, that is, learning to learn in new ways.
Learning to Unlearn
In med school, learners amass an incredible amount of new information and master a completely new language. Suffice it to say that “drinking from the firehose” probably understates the reality of undergraduate medical education.
Our schools inculcate lots of so-called “facts” into our students’ fresh minds, and said students suck up these facts like infinitely absorptive sponges. Sure, students often purge the data after cramming for tests, but they inevitably reclaim much of this knowledge over the next several years. And thus, students graduate medical school with their minds encumbered by extraordinary amounts of information to apply to patient care.
This approach unfortunately is faulty in two respects: Memory is imperfect, and facts are not immune to mutability. I have been caught on rounds reciting “facts I learned in medical school” only to have my team discover that almost no reputable sources can corroborate my claims — or even worse, that a reputable source completely refutes them. I cannot always pin down the etiology of my misinformation. I usually blame time’s effect on the faulty memory compartment. More importantly, I make a mental note to condemn that parcel of my brain and vacate it for future use.
My advice: Actively seek out the misinformation in your brain, and purge it. Identify what you thought you’ve learned but isn’t true.
Learning to Get Answers Without the Certainty of an Answer Key
As learners progress through their undergraduate and graduate training, they move from the black-and-white world of correct answers to a landscape of gray zones devoid of an answer key. Students often live and die by “what’s going to be on the test.” Even residents living in the oft-ambiguous world of clinical medicine have some anchor of certainty: the attending’s final word. No matter what shade of correct or incorrect a clinical decision is, the resident can often fall back on what the attending will want.
When there is no longer a judge of correctness — be it the professor, the course director, or the attending – it can be quite unnerving. In this situation, the teacher-learn should remember that “facts” you’ve learned are never truths. They are half-truths with varying degrees of evidence that can be variably applied to actual clinical scenarios.
My advice: When faced with situations where a correct answer cannot be known, gather all the information you can to make an informed decision. Remember that the teacher-learner becomes a de facto answer key, but be ready to adjust the grading rubric too.
Learning to Learn Critically
The learner role affords a certain luxury to students and residents: leaving all the critical thinking to the experts. For example, when you rotate on your cardiology rotation, you must recite gospel verses like, “Give an ACE inhibitor and β-blocker for everyone with reduced ejection fraction.” But what about that latest study on angiotensin receptor neprilysin inhibitors? Well, you get to leave the interpretation and its application to real-life settings to the renowned cardiology attending.
I am not saying that residents aren’t expect to think critically. But they often don’t have the time to learn critically: to analyze the latest developments and consider how to integrate the evidence into practice. Instead, students and residents defer or default to the experts (and integrate this information as “facts” into their brain; see sections above).
Now imagine what happens when no expert is present. The teacher-learner needs to be prepared to face situations in which he or she might be the one distilling very complicated data into spoon-fed “pearls.” The teacher-learner also needs to decide how much stock to put into his or her own truths.
My advice: Imagine how you would apply newly acquired knowledge to your patients before actually doing so. Someday you will not have an expert to lead the way, and you never know when your trainees might look to you for guidance.
February 11th, 2014
Paul Bergl, M.D.
Recently, our residency program had the excellent fortune of hosting Dr. Bob Wachter as a visiting speaker. Dr. Wachter is considered a pioneer in the hospitalist movement and has built his career around inpatient quality and safety. During lunch with Dr. Wachter, some of our residents, and hospitalist faculty, we discussed the topic of resident autonomy in the hospital. In the glory days of residency, I imagine that house officers experienced autonomy in its truest sense of the word: self-rule and utter independence. At least that’s the impression I have from Stephen Bergman’s (a.k.a Samuel Shem’s) House of God … a Lord of the Flies–like island inhabited by unsupervised and uninhibited junior physicians.
We all know that the 21st century’s inpatient environment leaves less room for such resident independence — and shenanigans, for that matter. Through regulatory and advisory bodies, patient advocacy groups, and our own recognition, we are now rightly focusing on other domains of hospital care. The main priority is not to “just let the doctors take care of patients how they want.” With this sea change, resident autonomy has evolved accordingly — both in practice and as a concept.
In case you haven’t heard, the quality and safety era is here to stay. Because true autonomy and “learning by doing” can potentially stand squarely at odds with quality metrics and the safest possible outcomes, I have to wonder:
- Will resident autonomy disappear completely in the future?
- How has autonomy changed already?
- And how will trainees learn to practice independently with all of this change?
Anyone that works in graduate medical education knows that duty-hour reform fundamentally shook the resident learning experience and thus affected autonomy. Since the additional 2011 duty hours changes were enacted, teamwork has become the name of the game. Residents routinely are forced to pass off decisions or depart before the implications of their decisions materialize. Attending physicians now seemingly shoulder more of the clinical workload, too, when residents’ shifts are truncated by a requirement to leave the hospital.
There is also probably universal agreement that the imperatives to reduce hospital length of stay and to facilitate safe discharges affect resident independence. As an attending, I know the pressures that the hospital is under, and I often feel compelled to be very directive about making prompt discharge a reality.
I doubt that residents would feel that either of these changes has eliminated their autonomy completely. Often in medicine, there is no single correct way to achieve an end. For this reason, residents can still safely be given leeway in many clinical decisions. There is still some art in what we do, and autonomy lives to see another day. But there are looming changes on the horizon that might threaten resident autonomy even more. Those that spend time in the hospital training environment recognize that all participants in inpatient care will increasingly be measured by how well they do their jobs. It is hard to conceive of a system in which residents and the attendings that supervise their care will be spared from aggressive quality improvement.
The stakes are simply too high nowadays. Health care is expensive and still unacceptably unsafe and unhelpful. With mounting pressures to provide higher value care, residents’ decisions are likely to undergo more scrutiny. Why is Resident A ordering more CT scans than Resident B? Why are Resident C’s patients staying in the hospital 2 days longer than Resident D’s? In my own experience as a chief resident, I know that residents still want autonomy. Heck, autonomy was my top priority in evaluating residency programs myself. As I have interviewed and met a number of applicants to our program during this residency match season, I sense that soon-to-be trainees are also putting autonomy high on their list of values. I like to tout my program’s emphasis on autonomy. I try to foster resident growth while attending on service by relaxing the reigns. I know the term autonomy doesn’t mean what it once did. Yet I do have hope that we can still give residents the leeway to “learn by doing” while preserving the health of the patients we serve and the financial stability of our healthcare system and our country.
January 13th, 2014
Akhil Narang, M.D.
During my year as a Chief Resident, I have the privilege to attend on the general medicine service for 8 weeks. I recently completed 4 weeks and, as expected, found myself in an entirely new realm of patient care and accountability. I would be remiss without recalling a few of the pivotal lessons and poignant moments that stand out.
Transitioning from resident to attending inevitably results in greater scrutiny. Despite my best efforts to prevent readmissions (especially within 30 days), I had several during my first month. A cirrhotic patient with a recurrent variceal bleed, a patient with sickle cell disease readmitted for a vaso-occlusive crisis after a sharp overnight temperature drop, and an older nursing home resident treated for a UTI who came back for seizures. Given the mounting pressure to prevent readmissions, I spent numerous hours dissecting the chart for each patient attempting to understand what went wrong and what I could have done differently. I discussed the cases with my co-Chiefs and several senior attendings. The consensus was that, in many cases, readmissions will happen. This was obvious to me as a resident but now, as an attending (especially an attending on service for the first time), I felt I had done something wrong. The increased scrutiny, coupled with a heightened sense of self-reflection, led me to forget what I learned over my years of residency — sick patients tend to get readmitted.
The ideal teaching service affords everyone the opportunity to teach. At the helm of a large team (one resident, two interns, two students, and a pharmacist), I did my best to demonstrate ultrasound IVC measurements in a hypotensive patient with heart failure before giving fluids, pointing out Quincke’s sign in aortic regurgitation, and reviewing sodium homeostasis in a patient with hypernatremia. For the first few weeks I was so concerned about being a good teacher that I neglected to be a student. Our team had admitted a patient who was struggling to breath and with newly diagnosed interstitial lung disease when my student gave a brilliant, unprompted presentation on the etiologies of ILD on rounds. Only then did I remember that my students, interns, and residents all know things I don’t. Giving them the opportunity to teach me is vital and surely won’t be forgotten.
As a resident, I took pride in efficiency. Suspicious lung mass in a smoker’s chest x-ray? No problem — I could coordinate the CT scan, bronchoscopy, and pulmonary function tests the same day. My seniors hammered into me that disposition is the goal. The longer the work-up takes, the longer the patient stays in the hospital. When fixating on the total patient census, it’s easy to neglect practicing good internal medicine. As an attending, while I respect the differences between work-ups of inpatient and outpatient problems, I also realize it’s ok to adjust asthma medications, initiate treatment for GERD, or talk about depression in a patient awaiting placement for hip fracture.
Attending on the general medicine wards has been one of the most rewarding, fun, and challenging experiences of my short academic medical career. I’ve learned too many lessons to enumerate, but perhaps the most important of all is to not lose focus on the foundation I built during residency.
January 8th, 2014
Paul Bergl, M.D.
At first glance, no diagnosis seems more terrible than cancer. Although it remains a huge killer in the developed world, cancer has also taken on new meanings in modern medicine. As an ordinary person, I certainly fear the word and would dread the diagnosis. Cancer. It has such a damning and unforgiving ring to it. After 3 years of residency in a tertiary referral center, where I’ve seen some of the worst cases conceivable, I still cannot imagine the painful and devastating odyssey that those who succumb to it must endure.
As a recently minted physician though, I fear cancer for other reasons. The science of the field is moving at a blistering pace. How can I keep up on the state-of-the-art treatments, genomic-based diagnostic tools, and molecular therapies? (When I talk about modern cancer care, I often wondering if I even talking about things that really exist.)
The care of cancer patients discourages this generalist, because it has become exceedingly complicated. How do I craft my words to distinguish “cancer” from “pre-cancer”? What advice do I give to a patient with recent biopsy-proven, localized prostate cancer? Will I be sued for negligence I didn’t offer chemoprophylaxis for breast cancer in a patient who develops metastatic disease on my watch? How can I watch expensive third-line chemotherapy being given to one of my patients while another patient eats his way to a cancer-causing BMI of 40 on a low-cost, high-carb diet?
Given these questions, I thought I would begin 2014 with a reflection on what cancer means to the general practitioner.
Cancer as Preventable Disease
Despite all the advances we have made in diagnosing and treating cancer, we still face awesome opportunities to curtail cancer before it even starts. During the past several decades, we have clearly made strides in preventing cancer, particularly in the realm of curtailing tobacco use. (Then again, tobacco use rates aren’t really all that different than they were 10 years ago.) And, all the while, our nation is growing increasingly obese — so much so, that obesity threatens to overtake tobacco as the major preventable cause of cancer.
Given these trends, I sense that progress toward preventing cancer has stalled. I also wonder if enough clinicians are even considering the fact that cancer is preventable at all. When I give the lifestyle pep talk in clinic, I am usually warning patients about risks for developing cardiovascular disease or diabetes, not cancer. I also feel somewhat powerless to affect a patient’s ability to avoid cancer through lifestyle interventions.
These days, we need continued dedication to training physicians to coach patients about lifestyle improvements. We also must bridge the divide between medical providers and our public health leaders and find more creative solutions than exploding cigarette taxes or rehashing ideas about food deserts, fat taxes, and junk food advertisements.
Besides preventing cancer by recommending lifestyle adjustments, the generalist must also augment his use of chemoprophylaxis when indicated. For example, even though the USPSTF reaffirmed its grade B rating for chemoprevention of breast cancer in high-risk individuals in 2013, most of us don’t adhere to these guidelines very stringently (NEJM JW Womens Health Apr 8 2010), especially compared with our adherence to other grade B recommendations, like mammography. We will have even more options as aromatase inhibitors emerge as chemoprevention, so we generalists will need to keep up to speed in this field. Of course, we might be able to use less targeted chemopreventive techniques, like aspirin for colorectal cancer and will need to know the risks and benefits of these options, too.
Less Screening and More Expectant Management of Cancer
Although oncologists might argue that “targeted therapy” or “pharmacogenomics” are the buzzwords that describe the future of cancer care, my own generalist-biased ears hear “overdiagnosis” everywhere. Most clinicians probably think of indolent prostate cancer and the PSA debate when they hear this term, but plenty of buzz surrounds overdiagnosis for other reasons. Part of the issue is the desire to redefine clinical entities that have often come with the bleak label of “cancer.” For example, the debate over DCIS has shifted from how to treat it to how we even describe it to patients. And, clearly, what we call DCIS does matter.
We also have new screening modalities that have generated excitement, such as the USPSTF and American Cancer Society’s endorsement of low-dose chest CT for lung cancer. Clinicians must remain circumspect about use of this screening tool though, as chest CT itself can reveal countless false positives and also carries serious risk for overdiagnosis. And, like the PSA/prostate cancer debate I’ve seen unfold over my training career, low-dose chest CT can lead to expensive, debilitating, and potentially deadly complications from biopsies and excessive cancer treatment.
All of this talk of overdiagnosis also makes me wonder where the medical community will draw the line on whom to screen. I wonder how willing the public will be to accept expectant management as a treatment option. The American Cancer Society already has published patient information for managing prostate cancer expectantly, but how often will patients with something more deadly — say, lung cancer — opt for “just watching it”?
Cancer at the Crux of the Medical Economics Arguments
Finally, all of these cancer-related issues are bound to intersect at the most timely of all topics in medicine: cost-effective care. That cancer care is extremely expensive is no secret. Thus, we will need to be more selective in our use of cancer treatment modalities. Will our payers begin to curb use of treatment modalities that do not confer a defined benefit for their cost, such as radiotherapy for prostate cancer? And on the question of cost-effective screening, will we continue to find more cost-effective ways to identify cancer early (like HPV testing every 5 years for detecting cervical cancer)?
Cancer is no longer the ultimate evil that must be detected early and destroyed at all costs. I don’t know that it ever was, but I do know that decision-making around prevention, detection, and treatment of cancer has become more nuanced than ever before.
December 11th, 2013
Paul Bergl, M.D.
As Dr. David Green reported this week in NEJM Journal Watch, the American Society of Hematology is the latest society to comment on appropriate and cost-conscious care in the ABIM Choosing Wisely campaign. I’ve followed the Choosing Wisely campaign closely and have been using it on the wards and in clinic as academic ammunition. A specialist society’s public advice about showing restraint is an excellent means to challenge the dogma of our so-called routine practices.
I know every conscientious practitioner has struggled with the high price of medical care. Our training environments are currently breeding grounds — and battlegrounds, for that matter — for ideas on how to solve our nation’s cost crisis. I have often wondered how we might change the way we train our residents and teach our students to exhibit financial diligence.
Of course, we are all part of this economic mess, and residents rightly share some of the blame. As naïve practitioners who lack confidence in diagnosis and management, residents tend to overorder and overtreat. I certainly have checked a thyrotropin (TSH) level in the inexplicably tachycardic hospitalized patient, despite my own knowledge that it was probably worthless. And I’ve seen colleagues get echocardiograms “just to make sure” they could safely administer large amounts of IV fluid for hypovolemic patients with hypercalcemia or DKA. When residents don’t have years of experience, they use high-tech diagnostic testing as a crutch.
Then again, the expectations of the learning environment also contribute to the epidemics of excessive echocardiograms and needless TSH levels. First of all, trainees are expected to have their patients presented in neat little bundles, devoid of any diagnostic uncertainty. Additionally, they have been trained through years of positive reinforcement for broad differential diagnoses and suggesting additional testing for unsolved clinical problems.
Although the Choosing Wisely campaign speaks to me and many of my generation, it is only a start. It alone cannot stand up to the decades of decadence and our culture of waste. How can we encourage trainees to truly choose wisely in the training environment? I propose the following:
- Deploy pre-clinical curricula that emphasize value-based medical decision-making. As much as students lament the breadth and depth of their curricula, pre-clinical students have fresh, open minds and are actually receptive to learning about cost-consciousness. We cannot expect that the curricula in residency or CME efforts will have an effect on our cost-ignorant model of care.
- Include cost-conscious ordering and prescribing in our board examinations. I have seen some change from when I took the USMLE Step 1 in 2008, but I notice that clinical board questions still usually ask for a “best next step” that usually doesn’t include “expectant management” as an option. As trainees prepare for these exams, they develop a line of thinking that then permeates clinical practice. When patients with chronic musculoskeletal complaints and unremarkable radiographs are referred for MRIs rather than receiving reassurance, we can put some of the blame on our licensing exams.
- Reward trainee restraint. Residents and students should be commended for not working up insubstantial problems, withholding unnecessary treatments, and showing prudence in choosing diagnostics. Again, our educational constructs are to blame, because we reward expansive thinking and “not missing” things. In morning reports and other case conferences, we often praise residents for adding another diagnostic possibility rather than exhibiting “diagnostic restraint” or cost-conscious care.
- Give trainees some sense of the cost and price of tests and treatments. The literature has not consistently shown that giving physicians cost or price information will prevent wastefulness. But as far as I know, these studies have focused on clinicians in practice who are wedded to their ways. From my experience, trainees thirst for this type of information. Frankly, we are all clueless about how much a chest CT costs. How much was the machine? Are there separate bills for the scan and for the radiologist’s interpretation? How much is the patient expected to pay? What will insurance pay?
- Get leadership buy-in at academic centers. I am neither a healthcare economist nor a chief financial officer. But my experience as a chief resident has taught me that buy-in from the academic leadership is necessary to turn the tide on monumental tasks.