Great comment on my high value cost conscious care post that accuses academics for excessive zebra hunting.  The comment is great because too often it really is true.

Our educational system rewards zebra finding more than conserving financial resources.  Too many academicians think zebras first and then default back to the obvious diagnosis.

One problem stems from our educational process being haphazard.  Rarely do we select attending physicians for teaching skills, or teaching philosophy.  We get faculty generally from three buckets:

1. Research future – can they get grants funded and produce important research
2. Clinical expertise – will they attract complex patients to the academic medical center because they are the expert for a zebra disease
3. Clinical need – sometimes we just need another body to see patients in clinic, or do endoscopy, or do cardiac caths

Only occasionally do we focus on teaching as a reason to hire someone.

When we hire any new faculty, we ASSUME that they can teach, and that what they will teach will have worth to the students/residents.  We do not really have department education goals.  We have a written curriculum that everyone ignores.

Some attendings do no go zebra hunting.  Some of us assume a horse (rather than a painted zebra), but will look for the zebra once the paint starts to crack.

I better write that concept more clearly.  The diagnostic process works best when we try an obvious diagnosis, and see if the patient’s problem representation (a short synopsis of their presentation) fits our illness script for the obvious diagnosis.  We should consider alternative diagnoses when the patient’s story does not really fit the illness script.

The key to zebra hunting is knowing when to hunt.  We owe it to our learners to make that decision explicit.  The onus of teaching this type of diagnostic decision making should fall on the entire faculty.  But first we would have to teach them some teaching principles.  And since teaching is, in my opinion, undervalued we will in the near future teaching students and residents that zebra hunting is a primary passion without regard to appropriateness.

How do we achieve high value cost conscious care?

The NY Times has an important and provocative piece – Overtreatment Is Taking a Harmful Toll

The title is a bit misleading.  The article focuses more on over testing.  We test too much and we treat too much.

The article, while mostly accurate, does not really explain the reasons for the problem  Unless we can accept and understand the underlying reasons for these problems, we cannot successful correct these problems.

Let me suggests the major reasons for over treatment and over testing and then address them over the next couple of weeks.  Prior to writing about each one, I do want to see if readers can suggest any more or disagree with the list.

1. Our payment system – that pays for each thing (i.e., diagnostic tests, visits) encouraging us to do more things.  We get paid the same when we spend less time with the patient and order more tests.
2. Advances in technology – we have better imaging and more laboratory tests.  Sometimes the tests are too good, and suggest that we do more tests.  Perhaps we should do more careful history and physical exams and do less testing.
3. Guidelines based on single diseases. We use too many medications to achieve targets that may help a disease but hurt other diseases.  Too often we have guidelines that do not give us enough “leeway” to individualize therapy.
4. Patient demand – patients think they need an MRI of the head, because a friend said so.  That friend knows someone whose 2nd cousin had a rare brain tumor found because of an MRI, thus you must get an MRI.
5. Malpractice fears – studies never document this, but all physician know that it is true.  This is especially true in emergency departments.  Every time I write this my comments fill up with emergency physicians justifying all the studies they do.  But ask any hospitalist about excess CTs in the ED.  The first abdominal CT for cryptic severe pain makes sense.  Perhaps the second, but certainly not the 5th, 6th and 7th.
6. Marketing from big pharma – leads to more expensive drugs and increased patient demand for those drugs.  This occurs especially from direct to consumer advertising.
7. Lack of information from other physicians – our obsession with privacy and HIPAA decreases the sharing of important medical information across sites.  Every time a patient sees another physician the order the same tests – easier than trying to get the old results.

I am certain that I have not been totally inclusive in my list.  This is really a multi-faceted problem.  Please add your thoughts.

Worry less about the errors and more about the responses

Atul Gawande wrote a fascinating piece that I originally missed – Failure and Rescue

Researchers at the University of Michigan discovered the answer recently, and it has a twist I didn’t expect. I thought that the best places simply did a better job at controlling and minimizing risks—that they did a better job of preventing things from going wrong. But, to my surprise, they didn’t. Their complication rates after surgery were almost the same as others. Instead, what they proved to be really great at was rescuing people when they had a complication, preventing failures from becoming a catastrophe.

This piece reminds me of a quote that I have used previously.  I searched down the quote and found this remarkable article – Chaos theory shows the wisdom of Plan B

James Yorke coined the term chaos theory.  He opines:

“The most successful people are those who are good at Plan B,” Yorke has said time and time again. This quote from several years ago has gotten as much publicity for its motivational wisdom as it has as a chaos theory concept.

Yorke explained that randomness happens from predictable causes. Planning for that randomness and having an alternative plan, will help prepare us for any obstacles along the way.

“It doesn’t necessarily mean you have to have a plan B to begin with,” Yorke said. “You have to look at how your situation is falling apart and try to act accordingly. Pick it up and run with it.”

Medicine represents a classic problem of chaos.  While most patients follow the expected course most of the time, sometimes things do not go according to the text.  Real success comes when we can modify our plan, moving to plan B.  Plan B usually does not come from careful advanced planning.  It really cannot, because too many different “failures” could occur, and we cannot spend the time to anticipate every problem.

The most successful physicians smoothly reassess the situation and develop a new plan.  We help our patients the most when we understand when to abandon plan A and develop plan B.  Gawande explains that well as does Yorke.  Interestingly they speak from different perspectives.

Compassionate paternalism

The NY Times has a most interesting letter – Invitation to a Dialogue: Arguing With Doctors

It sounds simple, but it’s not. I learned this when I had to decide whether to have a feeding tube during cancer treatment. Doctors explained the tube’s benefits and risks, then left it to me to decide. I said no. I had my reasons — I didn’t want a foreign object in my body or an overnight stay in the hospital. I wanted to prove that I was tough enough to get through treatment without extra help.

But this was a bad decision. As time passed, I became too weak to continue daily radiation sessions. People kept trying to get me to change my mind, and finally a nurse succeeded. Consenting to the tube was the right thing to do, but it took a lot of persuasion for me to accept that.

Argument is a legitimate part of shared decision-making, but not everyone understands this. Some clinicians think that respect for autonomy means they should never disagree with a patient. Some think that it would be cruel to question what a seriously ill person says she wants. Some don’t want to devote time to the hard conversations that produce good decisions.

We have, I believe, overdone the shared decision making concept.  Patients cannot really make informed decisions about everything.  We have a professional responsibility to provide our opinions and “argue” with patients about their health care decisions.

Almost all physicians argue with patients to stop smoking.  But is that not paternalistic?  We argue that patients should stop risky behaviors.

Why should we not have argued with the patient above about having a feeding tube?  This obviously intelligent patient did not understand the real consequences of her decision.

We have a responsibility to argue with patients when we clearly know best.  This responsibility should not become a slippery slope, thus our paternalism should fit my arbitrary definition of compassionate.

To abdicate our responsibility to give advice with the excuse that we do not want to appear paternalistic represents an unacceptable burden on patients.

Obsessed with a Mark Knopfler song

In the late 1970s, soon after I finished my residency, I heard a song – The Sultans of Swing.  Sometimes you hear a song and just know.  You just know that the group or singer has IT.  I quickly fell in love with the song and with Dire Straits.

In the 1980s I took a long trip and had about 6 cassettes with me.  One was Brothers in Arms.  I probably listened to those tapes 2-3 times each day for 2 weeks.  Yet I never tired of the group and especially Mark Knopfler.

For the past 16 years, the guitarist, singer and song writer, Mark Knopfler has become one of my favorite artists.  While I have 28 songs currently on my Knopfler’s Best playlist, I clearly could add more.  Many of his songs have captured me over the past 30+ years, but one stands out – A place we used to live

As I have pondered why I love this song so much, I wrote this commentary: