Vampires and Urban Legends: Teaching Residents about Healthcare Costs

24 05 2011

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States.  The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!).   How could I follow that…especially with a talk on how to train cost-conscious physicians?   Those who know my work well may even wonder how I got invited to talk about this.  Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees.   In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

  • Faculty are not trained.  The largest barrier of course is that faculty don’t know how to do this.  A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
  • No one knows what the cost of anything is.  Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost.  In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
  • Bad systems promote costly workarounds.  Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge.  The system is set up to order the test even if the attending thinks about it.  Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
  • Rumors and hospital legends spread quickly.  The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.
  • Underordering, not overordering, is penalized.  Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis.  More reasons doctors over-order tests here.

So what can we do to teach residents about cost-conscious practice?  Well here are just a few of the things we can do..

  • Empower residents to find out how much their hospital charges for things.  As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs.  Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
  • Show residents how much they spend.  At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks!  Studies with electronic health records at the point of care show even greater results!
  • Use unbiased resources that promote better cost-effective decisions.  Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities.   The popular 4 dollar list for medications is another example.
  • Incorporate discussions of costs into routine educational conferences.  At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like.  In our medical student lectures on radiology, the costs of the tests are also now discussed.
  • Educate patients that less is sometimes more.  Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine.   The pushback from patients may be the fear of rationing,  which is of course irrational since it already occurs.  A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.
As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine.  The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed.   This is especially important to watch out for as burnout sets in late in the academic year.  So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.
–Vineet Arora, MD




Twitter to Tenure: 7 ways social media advances my career

2 05 2011

As part of our SGIM Social Media Workshop “From Twitter to Tenure” our workshop lineup of ‘twitterati’ will be posting each day this week about how social media affected their career.   So yesterday was @AlexSmithMD on GeriPal.   Here is the schedule for the week:  Monday – me (@FutureDocs) here on FuturedocsTuesday – Bob Centor (@medrants) on DB’s Medical RantsWednesday – Kathy Chretien (@MotherinMed) on Mother’s in MedicineThursday – Eric Widera (@ewidera) on GeriPal (and hope to see you in Phoenix for our workshop!)

For the Twitter to Tenure workshop at this year’s Society of General Internal Medicine Meeting, I was asked to think about how social media enhanced my career.  This may sound ridiculous at first- after all, social media is a big waste of time right? Wrong as some of you have discovered.  Social media has opened doors for me by connecting me to a variety of people I would not have met.  Here is just a brief list of the ways social media has impacted my academic career.

  • Media interviews – I was interviewed by Dr Pauline Chen through the New York Times who located me through – you guessed it Twitter!  She actually approached me for the interview by direct messaging me through Twitter.  She was following me and noticed my interests in handoffs on my Google profile which is linked to my Twitter account.  She was also very encouraging when I started the blog which was exciting!
  • Workshop presentations- I presented a workshop on social media in medical education (#SMIME as we like to call it), at 2 major medical meetings with 3 others (including @MotherInMed who encouraged me to start a blog and also is my copresenter at SGIM).  The idea was borne on Twitter…and the first time I actually met one of the workshop presenters (who I knew on Twitter) was at the workshop.
  • Acquired new skills  – My workshop co-presenter who I only knew through Twitter ended up being Carrie Saarinen, an instructional technologist (a very cool job and every school needs one!).  She is an amazing resource and taught me how to do a wiki.  After my period of ‘lurking’, I started my own ‘course’ wiki  dedicated to helping students do research and scholarly work which we are launching in a week.
  • Lecture invitations – Several of my lecture invitations come through social media.  Most notably, I was invited to speak for an AMSA webinar on handoffs and also speak to the Committee of Interns and Residents on teaching trainees about cost conscious medicine.  Both invitations started with a reference to finding me through Twitter or the blog.
  • Committee invitations – I am now on the SGIM communications task force as a result of my interest in social media.  Our most recent effort was a piece about ‘tweeting the meeting’ with @medrants and an older piece focused on the top Twitter Myths and Tips.
  • Grant opportunities – I recently submitted a grant with an organization that I learned of on Twitter – Initially, I had contacted Neel Shah from Costs of Care asking him if they had a curriculum on healthcare costs.  They did not, but were interested in writing a grant to develop a curriculum so they brought my team on board and we submitted together (fingers crossed).
  • Dissemination - One of the defining features of scholarship (the currency of promotion in academic medical centers) is that it has to be shared.   Well, social media is one of the most powerful ways to share information.   In a recent example, we entered a social media contest media video contest on the media sharing site Slideshare.  Using social media, we were able to obtain the most number of ‘shares’ on Facebook on Twitter which led to the most number of views and ultimately won ‘Best Professional Video.’  To date, this video, has received over 13,000 views, which I was able to highlight as a form of ‘dissemination’ in a recent meeting with our Chairman about medical education scholarship.    While digital scholarship is still under investigation with vocal critics and enthusiastic proponents debating the value of digital scholarship in academia, digital scholarship does appear to have a place for spreading nontraditional media that cannot be shared via peer review.

Part of being a good citizen on social media is giving back.  I try to give back when I can through helping anyone who contacts me for something specific – so I have read personal statements, reviewed websites, and offered input to others who are interested in my perspective on their work.  I can’t always keep up since I have a day job and alas, this is an extracurricular activity.  The good news is a tweet is only 140 characters  – so like the blue bird, I can keep it short but sweet.

–Vineet Arora, MD








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