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Tags: advocacy, attending, conference, costs, diagnosis, doctors, healthreform, history of medicine, patient safety, payment, residency, women
Categories : residency training
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
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Tags: attending, doctors, dress, hospital, medical student, millenials, patient safety, professionalism, residency, women
Categories : career advice, hospital life, medical student
At a recent meeting I attended, a vigorous discussion broke out about what medical students, residents and attendings should wear, and more importantly what they should not wear. Interestingly, patients have been asked to weigh in on this discussion. What to wear is also on the mind of many current second year medical students who may find themselves trying to take study breaks from USMLE1 to go buy clothes for the wards. I also remember doing this as a rising third year student and wondering what to get. Here are some tips from our Associate Dean of Student Advising and Professional Development Dr. Shalini Reddy (@md2b_advisor).
- Don’t break the bank. Stores like Target, Marshalls, Sears or JCPenney are all fine places to get clothes for the hospital. You’ll be wearing your white coat over your clothes. Save your money for your fourth year interview suit.
- The hospital is a messy place. Buy clothes which you wouldn’t mind throwing out if you were drenched in body fluids. (Not likely to happen but would be devastating if you’re wearing Prada or Valentino).
- Buy comfortable shoes. You’ll be on your feet most of the day. There are actually studies that demonstrate that residents (who you’ll be following around) may walk up to 6 miles when on call! It’s hard to answer “pimp” questions if you’re developing bunions and wondering when the heck you can take off those shoes. You’re feet will thank you…
- Get a waterproof, inexpensive watch. You’re going to be washing your hands a lot. Being late to rounds is never good, but you may also lose your watch after you take it off to scrub in. A watch with an alarm can be very handy when you have to get up at 4 in the morning to pre-round for surgery.
- Scrubs are for the hospital not for home. As a New York Times article pointed out, no one wants to sit next to someone on the subway wearing scrubs, particularly those with uncharacterizable stains on them. Scrubs are there, in part, to keep you from taking hospital germs into the community. It’s also hospital policy. Unless a resident or student is staying overnight or involved with procedures, scrubs are a ‘dressed down’ look. So plan to change from scrubs to regular clothes before you wander around outside the hospital.
- Stock up on detergent, soap and deodorant. You’re going to be getting up close with your patients and if your clothes (or you) smell, they will feel even sicker than they already do.
- Buy a bleach pen. This is very helpful for spot cleaning blood stains until you can get your coat back to your house for laundering. Peroxide works too.
- White coats (and ties for men) are still part of the uniform. Yes, there are studies showing white coats and ties spreading infection. In the UK, they are already banning white coats. However, for now in the US, they are considered part of the standard attire for physicians and medical trainees and what patients have come to expect. In addition to washing your coat often, washing your hands is the #1 thing you can do to prevent infection.
- Wash that white coat. Those aforementioned uncharacterizable stains are really gross on white coats. Not a great way to instill confidence in your abilities with patients…or attendings.
- No perfume or cologne. Remember the triggers for asthma? Perfume is one of them. Stick to “eau de soap and water.” Beware the overly scented deodorant too. Unscented soaps are typically the best for combating malodors while avoiding elicitation of bronchospasm.
And some more tips especially for women
- Save the ‘Hospital Honey’ look for Halloween: Buy clothes for the hospital, not for going out: cover your cleavage, make sure your skirts reach at least mid-knee when you sit; shirts and pants/skirts should cover your midriff even when you raise your arms above your head. Remember, you are not dressed to kill, but dressed to heal. A patient actually called one of our attendings out for wearing loud, high heeled boots. An embarrassing reminder that we’re dressing for our patients not for each other.
- Minimize jewelry. Make sure you don’t wear anything too expensive to work especially if you know you’ll have to take it off (e.g. engagement ring gets taken off whenever you put on gloves). Get a safety deposit box if you’re worried about leaving your jewelry at home. Stay away from hoop or dangling earrings. Your stethoscope will pull off the hoops and kids will pull off the danglers. Besides, you’ll get germs on anything that’s not attached closely to your body (e.g. stud earrings).
- Wear OSHA compliant Shoes (no open toe). We know this is especially hard in the summer, when all the high fashion sandals and pedicured feet aching to show themselves. Do everyone a favor and keep your toes covered and save your fashion forward footwear for an evening out with friends. One of us actually took care of a female healthcare worker who had an IV pole run over their foot and contracted a MRSA foot infection – not fun! As a result, every summer, we are on the hunt for comfortable but good looking pair of “OSHA shoes”- it’s harder to find that it looks! DSW shoe warehouse is a good bet and won’t break the bank. Dansko clogs are also a safe bet and Crocs are now making comfy shoes without holes. Stay away from Crocs with holes which just provide pores for body fluids and needles To get to your feet.
- Hold off on the fancy manicures. Your nails have to be short and you’ll be washing your hands often. Nail polish does not stand up well to frequent hand washing/Purell.
Lastly, for all the 2nd year medical students out there, good luck on Step 1 and starting the wards!
Dr. Shalini Reddy & Dr. Vineet Arora