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!


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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


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Categories : hospital life, medical student, residency training

A Modern Day Fairy Tale for Medical Education

28 12 2011

Recently, I was asked to speak about innovations in inpatient medical education for leaders in general internal medicine.  Knowing that I would be last in a distinguished lineup of speakers and that my charge was to discuss novel ways to teach in the inpatient setting, I thought it would be important to review how its been done for a long time — so long that it is embodied in one of my favorite fairy tales…

You see, Cinderella dreamed of one day becoming the best clinical educator in the academic kingdom.  Unfortunately, her evil stepmom “Mrs. Dean” scoffed at Cinderella and said “teaching does not pay…look at your hard working and loyal stepbrothers….“Bill” has been our primary breadwinner due to his high volume of Patient Care and “Grant” –yes, while its feast or famine with him, just got a big payout for his Clinical Research.  Teaching? That’s no way to make a living.  Go work work for them until you figure you what you want to do.” 

So Cinderella toiled away…until one day, she met the Godmother of a grateful patient “Mrs. Fairy” who donated a small sum money to improve inpatient teaching…and with this Cinderella was able to transform herself into one of the leading teachers of the new curriculum (she was also able to get a raise to update her wardrobe!).  She quickly became a hit among all the medical students and residents who were truly “charmed”.  Then one day, at the stroke of midnight, Cinderella’s protected time ran out…and all of her work went up in smoke as she was forced back to her life of hardship seeing patients and doing research.  The students and residents were distraught at the thought of losing their most prized teacher and searched the academic complex for her –they were so moved they wanted to award her the precious “Glass Slipper” teaching award, which not only is bestowed with honor, but also a promotion to become a tenured educator in the academic kingdom.   And she lived happily ever after…

While you may think that this is the stuff of fairy tales (especially happily ever after), we all have Cinderellas at our institutions.  And those Cinderellas want to teach, but they struggle not only with funding, but also the realities of today’s inpatient environment.  So, what are these Cinderellas to do? Well, there are few of the ways to ensure that clinical teaching is rewarded – and possible resolutions for the New Year for medical educators.

  • Focus on a gap that needs to be filled:  Protected time is most likely be awarded to someone who is filling a need – think new curriculum that is mandated by LCME/ACGME or other alphabet soup organizational body.  What is the specific need that you can fill with teaching?  Often this may require thinking about a topic that may not exactly match your initial interest, but it is more likely to lead to funding for your teaching.
  • Learn new teaching methods:  Teaching methods for today’s wards are not well developed in the land of an organized chaos.  By incorporating a new platform for teaching (think case blogs, video reflection, standardized patients, or a host of other ideas), you can breathe new life into an old topic.  For example, using simulation to teach end of life discussion, or using blogs to teach about professionalism, can result in a novel curricular program that not only engage next generation learners, but also gains attention of leaders in medical education.
  • Document the effectiveness of the teaching – it is only through methodological evaluation that one can document that teaching translates into practice.  By showing that teaching can be linked to improvements in knowledge, attitudes, or practice, it is more likely that someone (maybe a fairy) will finance this teaching as critical to the mission of the hospital.  Think about procedural training that shows reduction in central lines.
  • Work with a mentor – Just like ‘big research’, mentorship is still important although not always emphasized. To be honest, mentors can serve to mobilize resources or promote your work with senior leaders.

However, regardless of these strategies, funding for teaching requires institutional leadership to recognize that the academic mission of teaching hospitals is still ‘to teach’.   Of course, this mission is sometimes lost in the chaos of teaching hospitals surviving budget crisis in an increasingly competitive environment.  So during this holiday season as everyone is reminded of the time of giving, now is a great time to remind the fiscally minded Mr. Scrooge in your C-suite that the greatest gift they can give is enabling a teacher to teach the future doctors of our nation.

–Vineet Arora MD


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