Help Debunk A Medical Myth About Patients Leaving AMA

11 07 2011

This week at FutureDocs, we are working with our friend and colleague Glass Hospital as well as one of our medical students and a recent residency graduate to bring to light a medical myth about hospitalized patients who leave against medical advice.  Here is an excerpt from his post about our work which includes a new Squidoo page created by Gabe Schaefer MS3 on what to do when patients leave AMA and the video vignette below.  Let us know what you think and please share this with anyone who you think may benefit!

Excerpt from this week at GlassHospital:

Like Mikey, the Life cereal kid who died from mixing Pop Rocks and Coke, or the spider eggs in Bubble Yum that help make it so soft and chewy, Medicine has its share of urban legends.  Did you know, for example, that if you’re hospitalized and decide that you want to leave “Against Medical Advice” [AMA], that your insurer won’t pay for the hospitalization?

Bunk.

Apparently, this canard is pervasively believed amongst doctors and passed from generation to generation of trainees just like the nonsense about cute ol’ Mikey.  A few years ago, a medical student came to me with a case of moral distress. She had seen the doctor-in-training with whom she was working become upset at a patient for declining an invasive heart procedure.

Rather than reason with the patient and convince her that the test was indeed indicated and would be of greater benefit than possible harm, the resident doctor in question quickly informed the patient that if she refused the procedure and signed out AMA, she’d be financially responsible for the entire cost of the hospitalization, as her insurer would decline to pay.

This left our student wondering if this was true, and if there were ethical safeguards against this.   Her moral distress led to a research project that debunks this notion [we hope] once and for all.

I can’t give you the specifics (an article on our findings is under review at a medical journal) just yet, but GlassHospital and FutureDocs are happy to share with you the educational fruits of our findings to date. You can click over here to learn more in true interactive fashion, or if you prefer, watch only the cameo-encrusted video tour-de-force right below. [Who is that guy playing angry Mr. Smith? He looks familiar. And who, for heaven's sake, does his wardrobe?]

Let us know your thoughts! On the video, the website, the urban legend. What other medical urban legends would you like to see debunked?





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





Useless Charts & Fresh Eyes in Handoffs

28 03 2011

Last month, I was a speaker for AMSA on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students.  They are not alone.  The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs – and they asked me to talk about it.  I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena about handoffs.  Would what I say be over their head and irrelevant if they had no clinical context?  I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case.  I had a lot of fresh eyes (and mostly ears) on the call.  In the vibrant Q&A that followed (and continued via email), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts- TMI? or Too much information.  This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver.  In hospitals with electronic health records, TMI is often a symptom of “CoPaGA” syndrome, or Copy and Paste Gone Amock.

But, this led to the most interesting debate of the night- why has the medical chart become so useless that people feel they need to use the signout this way?  I was asked to think about this question again later in a meeting with our Epic staff who are working to create an automatic signout system for our residents – they really wanted to know why we needed a separate system.  Since our residents have iPads, why couldn’t they just look at the record?

I had to think about that one.  I said that the chart is a document that is an archive that is most helpful for those people that know the patient.  It is also one large medical bill.  And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don’t know a patient and you have to make a quick on-the-spot decision.  So, this is why we can’t ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don’t know the patient.  The information there is overwhelming.  Our chief resident had a better answer.  The night resident needs the Cliff notes to answer the question since they weren’t assigned (and don’t have time at that moment) to read the full text.

Of course, handoffs are more than just the written information.   A handoff also has to include a verbal interactive component.  As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are ‘competent in handoff communications.’   I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure – I am on the editorial board).  Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs.  But, after I give a talk, I know that they may talk about it for a bit if I’m lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report.  However, these moments are isolated and as you can guess, education by itself will not translate into practice change (we could talk to the handwashing people all day about that!).   So, like handwashing, a monitoring plan is also needed and yes, that is also part of the new requirement- that programs actively monitor resident handoffs.

So as we head into July 2011, here’s to more fresh eyes…

–Vineet Arora, MD





Why you want a medical student to care for you

26 02 2011

Amid the buzz about whether medical students should be sued and the bill currently debated in Arizona (a state which finds itself in the spotlight more than usual these days), I noticed some commentary from several people who do not think they would like a medical student on their case.  Sometimes patients do refuse to be cared for by medical students, often due to overestimating the involvement they will have in their care.  Indeed, there is an inherent tension between patient safety and the need to train future physicians.  However, it is important to recognize there having a medical student caring for you may actually be a blessing in disguise.  There are several reasons why you may benefit from having a medical student caring for you. 

  1. You will have a complete history and physical on your chart– There is often not enough time for a resident or attending to do a thorough history or physical.  Their documentation is not likely to be as complete as a medical student’s.  Interestingly, the best friend of every consulting physician is the “medical student H&P” – the history and physical document that details all the major information about a patient’s stay.  While patients often report they are ‘repeating’ their story to everyone they see, part of that is due to an incomplete history that necessitate treating physicians to delve a bit more to confirm the diagnosis.   Unfortunately, with the advent of electronic health records, medical student histories are sometimes not part of the medical record.  However, it does not  have to be the case.  At one of our community hospitals, our students notes do appear in the system and are able to contribute to the care provided.
  2. Someone will check in on you frequently and have time to listen to your questions – Because medical students don’t often have the caseload of the resident or attending, the student is able to pay more attention to you throughout the day.  A third year student may be following only one or two patients at a given time.  While it is true that maybe they don’t know all the answers to your questions, they can relay this to your team and often serve an invaluable role.
  3. They may make you feel better- Students are often less burned out and more connected to their patients since they are learning from each of their interactions.  I’ve had students who really connect to patients through a variety of ways to help them heal, including reading to them or bringing them their favorite magazines or books so they don’t get bored.
  4. You may get fewer tests – While it may appear that a medical student may be associated with more testing, the truth is that the job of the medical student is often to ‘get old records’ from the outside hospital or the primary care physician.  Unfortunately, this is very time consuming and hard to do and it is not easy to “check the record” as patients often ask us to.  Maybe this will get better with electronic health records that talk to each other, but in the interim, we rely on our students.  Unfortunately, residents do not have time to do this these days with the caseloads they carry.  For example, last year, I had a medical student who secured the invaluable bone marrow biopsy on a patient from an outside hospital on a weekend(!) that saved the patient from getting an unnecessary and painful procedure.  A few weeks ago, I had a medical student who secured a bevy of rheumatologic and hematologic labs on a patient with a suspected autoimmune process which saved us from having to redraw all of those tests.
  5. A student may actually make the diagnosis– Students are sometimes assigned to the ‘bread and butter’ cases (routine stuff) but are occasionally assigned to the ‘zebra’ – the interesting case that no one can figure out.  While students don’t have all the experience that their more seasoned and older residents and attending have, they do have time to look things up and can sometimes make a breakthrough since they keep a wide open list of possibilities.  Over the past few years, I can recall several instances in which a patient’s diagnosis was a mystery and a massive workup was ongoing with multiple consultants involved.  In two instances, a student offered the correct diagnosis early in the patient’s course and found key literature to secure getting the right test.  In another case, a patient who was in the hospital became very concerned about her nail findings (which was her number one complaint) despite having a serious heart infection.  After some digging, our student figured out the diagnosis was Muerkhe’s nails, which is a finding associated with low protein, and he was able to reassure her that they would go away as her nutrition improved.

While some of you may still have concerns, it’s important to know that students are closely supervised by residents and attending, who are the ones responsible for your care.   In fact, the patients cared for by students sometimes get more attention during rounds by the resident and attending.  So if you or a loved one find yourself in a teaching hospital, consider asking for a medical student on your case.

-Vineet Arora, MD





The Film Clerk, the Radiologist & Technology: Friend or Foe?

19 02 2011

During my last two weeks on service, whenever we ordered an MRI or a CT, I wondered was this scan necessary and will it really change care?  In addition to increasing scrutiny on the perils of unnecessary radiation, the blogosphere was abuzz about this topic (see Bob Centor and Bob Wachter among others).  Coincidentally, our grand rounds speaker last week was Dr. Bruce J. Hillman who is the chief of the Journal of the American College of Radiology, and recently coauthored a book on the subject titled the Sorcerer’s Apprentice: How Medical Imaging is Changing Health Care.  

Many of Dr. Hillman’s observations were spot on – radiologists hedge – they overcall things due to concerns they will miss something.  An overcall is better tolerated than a miss.  As a result, many patients are diagnosed with incidentalomas or pseudodisease that could lead to other costly workups and expose them to unnecessary radiation.  How can a clinician ‘ignore’ the overcalled incidentaloma in the world of malpractice?  Dr. Hillman also spent a lot of time discussing the overreliance on scanning in teaching hospitals.  In the busy overworked environment in many hospitals, it is easier to get a scan than do a thorough history and physical exam.  (This is assuming that physical exam skills are actually good enough to pick things up). 

Unfortunately these days, residents actually have LESS time for history and physical.  With duty hours, the chance they actually met a patient on admission and obtained the history is lower.   There is also less time to make a decision.  With pressure for shorter length of stays coupled with system inefficiencies, if you’re not in the queue the day before for the imaging test du jour, you will add on an extra day just to get the test.  Lastly, while fear of litigation does play a role, physicians also worry about backseat quarterbacking and looking bad in front of peers.  For example, I often thing to myself, if this patient comes back to the ED with the same complaint, would those physicians think I was crazy for not getting a scan?   Because imaging often helps make the right call, the question is when is it appropriate or inappropriate? 

This is when radiologists have traditionally come in.  When I was a resident, I recall going down to radiology and asking the film clerk to get my films (in fact, being friends with the film clerk was as important as being friends with the nurse).   After waiting patiently in line in the dark room for the next available radiologist in the specialty of interest, I ‘presented’ the patient with a one liner and the specific clinical question.  The radiologist would then reread the films and discuss the case, often asking for more questions.  At the end of this conversation, I often had a plan which usually did not involve another scan.   

While technology has replaced our trusty film clerk as our greatest friend, it has also become our worst enemy.   Today, I can look at images on the computer, even on the iPads that our residents carry on rounds, and eagerly await the ‘final read’ by the attending.  Ordering tests has also become easier.  Most of my time as an intern was spent calling down to radiology convincing them I needed the test.   That is in sharp contrast to today when orders are just entered electronically with a drop down selection of ‘reasons’ that include ‘r/o pneumonia’ or ‘dyspnea’ (fancy medical term for shortness of breath).  No wonder most of the reads come back as “suggest clinical correlation.”  

So, how do we fix this? Well, Dr. Hillman highlighted the need to start early in training – essentially to teach students and residents to do this better.  So, this past week at a curriculum meeting, I was pleased to learn that one of our expert radiologists would be formally integrating radiology into our third year IM clerkship, including costs of testing and appropriateness of tests.  However, we all know this will not change anything if the faculty are pushing for the scans.  Professional organizations have recognized this, and started to offer guidelines for practicing physicians.  Earlier this month, the American College of Physicians released guidelines calling for internal medicine physicians to minimize scanning for low back pain.  The American College of Radiology has released  “appropriateness” criteria for a variety of clinical conditions which include the radiation risk for each test.   Since faculty may or may not see guidelines,  Massachusetts General Hospital has gone one step further, embedding these criteria into the electronic ordering system for radiology testing as a hard stop, which offers suggestions for low yield exams and require that a physician override the system to proceed.  Indeed, technology can be a better friend.  Perhaps, another solution is to talk to our old friend the radiologist.

-Vineet Arora, MD





Student Doctor or Medical Student? And Other Teaching Hospital Names

14 02 2011

I recently saw a post in Yahoo questions entitled, “Is it illegal for a medical student to introduce themselves as “Doctor” before they have received their MD?”  One of the answers that was rated highly was “I think it is more unethical than illegal.”  Clearly, if a student is deliberately misrepresenting themselves as a ‘doctor’, it is grounds for disciplinary action.  More often than not, this misrepresentation is not deliberate on the part of the student.  For example, some of our prior work demonstrates that medical students often report that they were introduced by other physicians as a doctor to a patient and that to a lesser extent, students may not correct someone who mistakes them to be a doctor. 

Complicating matters is the propagation of the term “student doctor” at some institutions which is especially problematic.  After all, how many patients will be quickly discern that ‘student doctor’ actually refers to ‘medical student’ and not a ‘doctor’?  Unfortunately, patients who hear the term ‘student doctor’ may not hear the term ‘student’ and just zero in on the ‘doctor’ part, as they often wait patiently for their doctors to see them in the hospital.   This brings us to the problems of how doctors are named in teaching hospitals.  The system could not be more confusing.  

  • Interns – This is probably one of the most confusing terms in a teaching hospital.  Interns are doctors who have graduated medical school and are in their first year of a residency training program.  Of course, ‘intern’ is also the universal term for all those college students trying to get a short term experience on their resume by ‘interning’ there first.  So, why would a patient think an intern is a doctor?   After all, you would never put your faith in the legal ‘intern’ at the law firm to defend you in a lawsuit.   To make matters worse, there is the opposite problem.  Intern is often mistaken for ‘internist’, who is actually a doctor who has completed their internal medicine residency and otherwise a ‘doctor for adults.’  (Patients are more familiar with their “PCP” or ‘primary care physician,’ which could refer to either an internist or a family physician).    
  • Residents – Residents can refer to any doctor who has graduated from medical school and is in a residency training program (including interns). The term “residents” originates from William Osler’s era when residents did live in the hospital.  Of course, they don’t live there anymore  which would violate worker’s rights not to mention their regulated duty hours… but we still call them residents.  The other name residents are often referred to is as “PGY1” (post graduate year) which is certainly not an improvement.  
  • Housestaff – One of our premed college students just asked me what this term was this week.  I explained that while this does sound like the butler, maid, or cook a fancy estate, this term actually refers to the hospital as the “house” that the residents live in as the staff.  So all residents (including interns) are part of the ‘housestaff’. 
  • Fellow – This is perhaps one of the most disconcerting names for a physician as it may sound like it refers only to male doctors (and conjure up images of young man from England with excellent manners i.e. he’s a fine ‘fellow’).  In fact, a fellow is a doctor who has completed residency and is getting advanced training in a certain subspecialty. 
  • Attending- Attending to what you may wonder?  The attending physician is actually the doctor who has completed training and is legally responsible for the care provided by residents.  In other words, this is the ‘boss’ doctor as my residents sometimes introduce me to the patients on our team. 

A few years ago, we tried to improve the situation for our patients by having doctors introduce themselves with baseball cards with their pictures on the front and the roles of the doctors were displayed on the back.  While we were able to increase the percentage of patients who knew who their doctor was, we were surprised to discover that fewer patients stated they understood the roles of the doctors.   How did we make it worse?  Perhaps ignorance is bliss.  By trying to unlock the secrets of these names, patients realized the names we use in teaching hospitals are confusing.

However, this confusion is more than just a name, it is also a patient safety issue.  After 18 year old Lewis Blackman died in a South Carolina teaching hospital without an attending evaluation when his family kept asking to see the doctor, a new law in his honor aims to address the issue.  It requires that patients receive written materials describing the roles of the trainees on their team and also how to contact the attending if they have a concern.  More recently, the ACGME, which accredits US residency programs, has included a mandate in its now infamous policy restricting resident work hours that states “residents and faculty members should inform patients of their respective roles in each patient’s care.”  While it is not certain how this will be implemented at every teaching hospital across the land, it’s certainly time to make our naming system easier and more transparent for patients to understand.

 –Vineet Arora, MD








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