What Happens in Vegas Can Be Used to Teach Costs of Care

16 02 2012

Funded with a grant from the American Board of Internal Medicine Foundation,  Costs of Care has partnered with medical educators at Harvard Medical School and the University of Chicago (that would be us!) to start addressing this problem. We are developing a series of web-based medical education videos that use clinical vignettes to illustrate core principles of cost-consideration, including how to communicate with patients about avoiding unnecessary care and reducing overused or misused tests and procedures.  As part of the project launch, we released a new teaser video today called “What if Your Hotel Bill Was Like a Hospital Bill?”. The video is a tongue-in-cheek depiction of the challenges patients face in deciphering medical expenses, and their additional confusion when they learn doctors are not trained to consider costs.  - Excerpt from Costs of Care Press Release by Dr. Neel Shah  

How does this relate to Vegas?

On a recent trip to Las Vegas with my family for the holidays, I was in the Bellagio lobby admiring the Chihuly glass ceiling.  While that was impressive, I was also watching the clerks check in and out the long lines of visitors to the hotel.  The staff explained any charges on the bill, confirmed that the bill agrees with the expectations of the patron and then finalized the transaction, printing a copy on the spot for the traveler before they got in the cab to the airport hailed by the bellman.   What a far cry from hospitals where most of the hospital staff have no idea how much anything costs!  After all, doctors are notoriously bad at considering costs in the doctor-patient relationship, as demonstrated by a great piece by Dr. Peter Ubel on his experience with the cost of his own prescription medications. As Paolo (or Paul who works as our research project manager in his day job) from Hotel Hospital highlights, “our hotel staff specifically focus on the highest quality of care…I doubt that they even know how much anything costs here.”  The rest of the script was easy to write.  Shooting was a lot harder since we had to find a spot in the hospital that looked like a hotel but thanks to some creative camera angles and props from our MergeLab team, we were able to get it done.

Learning about costs of care is critical to taking care of patients.  This was especially poignant during my recent inpatient service block at a nearby community hospital, since I cared for many uninsured patients who paid out of pocket for their medications (not to mention their hospital stay).   Our residents were concerned about one patient who was uninsured and would have difficulty paying for Plavix, a critically important drug after his heart procedure.  Review of his medications also revealed he was recently put on Lexapro, a nongeneric antidepressant (with a sordid history) that was costing him over 100 dollars a month when there is a generic alternative for 4 dollars a month, which would help him afford his Plavix.   When physicians do discuss costs, they also get it wrong and perpetuate a ‘medical urban legend’ like stating that patients have to pay when they leave the hospital against medical advice (this is not true!).   These are just a few of many examples of why teaching students and residents to bring up costs and arming them with tools to address the issue with their future patients is imperative.  Without considering costs of care, we all take a ‘gamble’ that costs of care are not an issue for patients….Of course, the odds are against that.

Stay tuned for more work from our Teaching Value Project from Costs of Care funded by the ABIM Foundation. 

–Vineet Arora, MD, MAPP

Special thanks to our production team and actors: Mark Saathoff , Andy Levy MS4, Kimberly Beiting, Paul Staisiunas, Jeanne Farnan, and Neel Shah!





The Social History: Going Beyond TED

7 02 2012

As I am on service, I realized that one thing that can be easily lost in the race to take care of patients with limited duty hours – the social history.  The social history is part of the admission “history and physical” that once included a myriad of information about the patient’s job, life, and habits has now “fallen into despair” becoming little more than “negative for TED”, or in other words “no tobacco, alcohol (ethanol) or drugs.”

But, there is so much more to it than that.   How do they afford to pay for their housing, food, and medications?  Do they have insurance?   Where do they live?  Who takes care of them or do they take care of someone else?  Do they have friends or family living nearby?   What do they like to do for fun?  Given that most of the ‘discharge planning’ focuses on these elements of the social history, it seems silly that we don’t include more than just no TED.

So, when I was asked by a very astute medical student if I preferred to hear more in the social history, I said yes.   The information that is usually discussed as the patient gets better and we wonder where they will go was now presented on admission, discussed as a problem just like any other medical problem.   In just a few short days, we discerned that a patient who had chronic hypoxia and shortness of breath worked in a factory which likely contributes to his interstitial lung disease.  Another patient who had been hospitalized for alcohol withdrawal recently broke up with a girlfriend which triggered this bout of drinking.   Another patient who was a Jehovah’s Witness would rather have IV therapy for his wound infection than surgery.  Another patient with repeated hypertensive crisis had skipped his medications since he could not afford them.

Given the tremendous burden of costs of medications and the complex interplay between social factors and health, it’s time that we start teaching people to take a thorough social history. Wondering what should go into a thorough social history, I first did what most physicians do – I went online.  It turns out that Wikipedia has an entry on social history for medicine that starts out with the same substance abuse history.  It also includes occupation, sexual preference, prison, and travel.   I stumbled upon another interesting piece by a medical student in the LA Times who admits that it is easy to skimp on the social history due to the time it takes to take a complete history.  After a brief foray in PubMed, A study demonstrated that internal medicine residents do not often know the social history of patients, and this worsens if the resident is more advanced in training and when the workload is higher.  Then, I recalled the seminal text that is still in use today.  According to the Bates Guide to History and Physical Examination:

The Personal and Social History captures the patient’s personality and interests, sources of support, coping style, strengths, and fears. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). It also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise; usual daily food intake; dietary supplements or restrictions; and safety measures and other devices related to specific hazards. You may want to include any alternative health care practices. You will come to thread personal and social questions throughout the interview to make the patient feel more at ease.

There is another good reason to teach the social history – another study shows that those residents who took better social histories were actually perceived to be more humanistic.  As others stated, “By knowing patients better—and taking better social histories—we will provide better care and will be more fulfilled and energized in our work as physicians.”

–Vineet Arora MD





The Last Summer for Medical Students

12 01 2012

The summer between first year and second year of medical school is sometimes referred to as the “last summer” since it is the last time students can travel or take off before they start the journey towards USMLE Step 1 and then their third year clerkships.  With the angst building, first year medical students are actively deciding in the dead of winter what they will do over the summer.  One popular decision is to do research – this is not uncommon since residency programs are increasingly competitive and look for students who have a commitment to scholarly work.  However, there are a plethora of other things students could do as well.    As tonight is our “Intro to our Summer Research Program” for Pritzker medical students, I thought I would share some of the most common questions I get about the “Last Summer”:

  • Should I do research in a competitive field?   The answer here is to do substantive research that you are interested in with a “CAPE” mentor (Capable, Available, Project interests you, Easy to get along with).   As my premed advisor once told me, “Mickey Mouse” research is not going to look good to anyone (no offense Mickey).   The key is to find something you are passionate about – after all you have to tell this story on your interview trail of why you choose to do this and the answer “because I wanted to go into ortho” is not really that captivating to anyone (even to an orthopedic surgeon).   Instead, if you do something you are passionate about, like community health work, you can always tie it back to your chosen field.  Most residency program directors don’t expect you arrived in medical school with laser like focus towards their field anyway and expect to hear some type of journey or a-ha moment that drew you to their field.  Because competitive specialties are often reimbursed for clinical work and tend to be smaller departments, they depth of research opportunities may be more limited.  But, don’t forget that neuroscience research is relevant to neurosurgery – and oncology research on head and neck cancer is still relevant for ENT and so forth.  The best research is often interdisciplinary and crosses department boundaries so you should not be afraid to either.  It’s also important to remember that as a first year student, it’s hard to even know if you will be competitive for radiation oncology or associated competitive specialties.  You will need killer board scores, and great clinical grades.  So, while you may think securing the research with the Dept Chair will give you an extra ‘edge’, nothing and no one can make up for a poor performance on high stakes exams or clinical rotations.  So, don’t forget to study!
  • I want to go to country X?  How can I get a global health rotation there?  Well, certainly the urge to travel is strong in anyone (including me).  But, you need to separate your travel bug from a genuine interest in global health.  Most global health rotations are not a vacation – and may not be what you think of as “tourist” destination (despite the short-lived popularity of Off the Map).   Maybe your stars are aligned and your school or a nearby affiliate you know has a program near your hot spot of interest.  Usually, however, it is not that easy and you should consider how strong your affinity is for a specific country or location versus your interest in getting the best global health experience possible.  Global health programs that fund medical students are not easy to come by.  So, if you are genuinely interested in global health, it is always better to go with an established program and mentor to get the most substantive experience even if it’s not in the exact country you are interested in.  The other thing to remember is while this may be your last summer for a while; it is not your last vacation!  You will have time to plan a vacation to your designated hot spot if you can’t work it in this summer.
  • Do I have to do anything?  The answer here is easy – no, you don’t have to do anything per se with your ‘time off’.  Many students find themselves on the hamster wheel of endless extracurricular activities.  The real question is what is your goal? If it is to go home and see family and friends, there is nothing wrong with that!  The key is to ensure that you are doing something with your time off that will make you feel ready to face the second year of medical school.   It is easy to forget that there is a lot of time to participate in extracurricular activities at various other points in your medical school career.   The key is that if you will regret not spending time with your friends or family this summer, then you need to make time to do that.
  • What if I want to do everything because I don’t want to close any doors?  This is not an uncommon feeling for medical students. However, its important to remember that your summer work is not choosing a specialty! There is essentially nothing you can do over the summer that will ‘close a door’ – there may be some things that allow you to put your foot further into the doorway but that does not mean another door will close.   The only doors you close are the ones in your mind.   Most students decide on their specialty after their third year rotations and will often fine-tune their experiences in research in that area in the fourth year.   Another thing to consider is to do research in a cross-cutting area like ethics that could apply to everything.  Sometimes the angst you may be feeling is about making a choice that is wrong for you.  However, the truth is that as long as you are genuinely interested in the opportunity, you cannot make a wrong choice since it will be an easy story to tell no matter what you do.  Since everyone is different, it is always good to get individualized advice from a faculty advisor at your school who can comment on your specific career and research goals.

Finally, no matter what you do with your last summer, don’t forget to make sure you enjoy it!

Vineet Arora MD








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