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An article in Forbes magazine entitled “Mark Cuban Doesn’t Understand Health Care” highlighted a series of tweets sent out by Mr. Cuban telling his 2.8 million followers to obtain quarterly blood tests in order to “have a baseline of your own personal health.” The Forbes piece focused on the “problems with Cuban’s argument” and included an exchange between the businessman and Charles Ornstein, a Pulitzer Prize-winning reporter with ProPublica who challenged Mr. Cuban to provide evidence that these tests have any benefit to patients.
This guest post was submitted by winners of the ABIM Foundation and Costs of Care Teaching Value and Choosing Wisely Challenge.
“It’s important to teach the principles of cost-conscious, high-value care, but how do we enable our medical students to actually practice it?” This question gripped our group of clinician educators gathered at the Millennium Conference on Teaching Value-Added Care in 2013. Students needed authentic opportunities to apply High Value Care (HVC) knowledge and practice HVC skills. Additionally, our own institutions needed to prepare for the shift from fee-based care to value-based care. We had a big idea: medical students would not only practice HVC, but they would also serve as change agents at our teaching hospitals to encourage HVC.
We acknowledged many obstacles to teaching students about HVC. Most clinical faculty who teach medical students during patient care delivery have not been trained in HVC. “Value” frequently does not enter the busy clinician’s mindset and consequently, students may not observe HVC being modeled. Our current health care environment emphasizes action, through sophisticated tests and invasive procedures, without meaningful consideration of the risk of harm to patients. Given the rapid pace of clinical care, it is no surprise that the clinician educator would find it challenging to remember to teach HVC during patient care activities. We needed to develop a method to remind students and their teachers to consider value and to embed that process in their workflow.
SOAP-V emerged as a modification of traditional “SOAP” presentation (Subjective-Objective-Assessment-Plan), adding “V” for value. This framework creates a cognitive forcing function to promote discussion of HVC during patient care delivery. The SOAP-V model prompts students to consider several questions:
1) Before choosing an intervention, have I considered whether the result would change management?
2) Have I incorporated the patient’s goals and values, and considered the potential harm of the intervention compared to alternatives?
3) What is the known and potential cost of the intervention, both immediate and downstream?
In the summer of 2014, we collaborated to implement SOAP-V for third-year medical students during their internal medicine clerkships at our home medical schools: Penn State College of Medicine, Harvard Medical School and Case Western Reserve University School of Medicine. We developed HVC teaching materials, including a video, PowerPoint presentation and role-playing exercise that could be taught within 45 minutes. The students received a SOAP-V card and the HealthCareBluebook.com Web address to research costs, and then used SOAP-V during patient rounds in the hospital.
Biweekly surveys and direct observation confirmed that third-year medical students are using the SOAP-V tool at our medical schools. Trained students report increased comfort in initiating discussions about unnecessary tests or treatments with their teams, increased power to address the economic health care crisis and increased consideration of potential costs to the health care system when making clinical decisions compared to the control group of students who did not receive the SOAP-V intervention.
By using SOAP-V, medical students can demonstrate the application of HVC on teams to both resident and attending physicians. Our next steps will be to gauge whether resident and faculty attitudes about HVC have changed, as well as to embed SOAP-V in other clerkships, and to promote the use of the SOAP-V tool within corresponding residencies.
Drs. Eileen Moser and Susan Glod from Penn State Milton S. Hershey Medical Center; Drs. Sara Fazio and Grace Huang from Harvard Medical School; and Dr. Clifford Packer from Case Western Reserve University and the Louis Stokes Cleveland VA Medical Center, modified the traditional SOAP note template to include a discussion of value. The team was a winner of the 2nd Annual Teaching Value and Choosing Wisely Challenge.
I recently attended a presentation by Mark Bonchek of thinkORBIT where I was inspired to reflect on the past three years of Choosing Wisely® and how the campaign reflects a cultural shift both in society at-large and in the way businesses operate. This shift has roots in self-determination theory, complexity theory, co-creation and digital strategies like those espoused by Bonchek.
1) Moving from managed processes TO ones with minimal rules/principles and maximum flexibility
Choosing Wisely gave societies four simple rules to guide them through the creation of their lists of tests and procedures. The recommendations needed to be:
- frequently done or costly;
- within the control of the specialty; and,
- created using a transparent process.
2) Moving from control TO autonomy and respect
Choosing Wisely respected the societies’ unique knowledge and mastery of their particular specialty areas, and empowered them to develop their own credible processes for creating their lists.
3) Moving from hierarchical/top-down relationships TO non-hierarchical, bottom-up ones
In the absence of a centralized authority or bureaucracy, more than seventy societies have joined the campaign. They, in turn, solicited the opinions of many physicians in their society, getting them to buy into the campaign during the process.
4) Moving from product creation TO a platform
The Choosing Wisely website contains the lists of recommendations, and resources are available on both the ABIM Foundation and Consumer Reports sites. All parties, including regional health collaboratives, medical associations and delivery systems, use the information on these websites to help them develop their own local strategies for implementing the recommendations and changing attitudes.
5) Moving from one-way communication TO community- and relationship-centered communication
The Choosing Wisely campaign is comprised of over one hundred organizations united by a single purpose. They communicate with each other through learning networks, bulletin boards, newsletters and many websites. This supportive, respectful, relationship-centered community is key in the promotion of shared decision-making conversations between patients and physicians.
6) Moving from competition TO collaboration and co-creation
Rather than having “expert” or oversight organizations develop the lists, the Foundation urged the societies to encourage its members to “co-create” their lists. Volunteer physicians associated with the campaign reviewed the recommendations primarily for clarity. Particularly in the early phase of the campaign, specialty societies worked collaboratively to design the format of the two-page recommendation sheets and the information included (e.g., conflict of interest disclosures).
Physician empowerment and leadership is what is attracting many to this campaign. I think these principles could be applied to all types of desired physician engagement strategies. It is a new culture and a new way of doing the work that is producing such engagement. Organizations that are implementing Choosing Wisely are also using the above principles to design their interventions with great results.
It’s a new dawn – it’s a new day.
A recent article challenged the Choosing Wisely recommendations around routine stress testing before low-risk surgeries. The article, “Stress Testing Before Low-Risk Surgery: So Many Recommendations, So Little Overuse” suggested the campaign’s partners focus on services with “high baseline rates of inappropriate care.” In her Editor’s Note in the same issue, Rita Redberg, MD, called for the specialty societies to create bolder recommendations about tests and procedures that patients and physicians should question. Both articles agreed that societies should adhere to the campaign’s charge to reduce unnecessary care.
One of my relatives has metastatic cancer. He has several tumors in his body, one of which measures five centimeters. Two chemotherapy regimens have failed to beat back the disease. Yet, when he’s not in treatment and has no pain, he is able to go about the daily activities of his life, even going to work. If it wasn’t for his hair loss due to the chemotherapy, you wouldn’t even know he is seriously ill.
After consulting with his siblings and loved ones, he recently entered a Phase 1 clinical trial. The clinical trial is testing an immunomodulator, based on the theory that the body’s natural immune system can be recruited to act against the cancer cells.
Regular readers of this blog know I support the adoption of lean methodology to eliminate health care waste. So, it was with great pleasure that I accepted an invitation from Oregon Health & Science University’s (OHSU) Chief Medical Officer (and my friend), Chuck Kilo, to visit his academic medical center and speak about Choosing Wisely®. OHSU has been a proponent of the lean philosophy for several years and I was excited to learn how the organization was applying it to make improvements in quality, safety and professionalism.
Physician and patient organizations alike have increasingly emphasized the importance of improving value in health care and reducing unnecessary (and potentially harmful) care. Choosing Wisely®, the ACP’s High Value Care initiative and other programs have successfully stimulated interest and conversation, but what actual steps to take to improve value in hospitals is not entirely clear.
How can we move from interest to action to improve the quality and appropriateness of the care we provide to our patients?
We’ve feted the new year. Now it’s time to assess that list of resolutions.
Through the Choosing Wisely® campaign, Costs of Care and the ABIM Foundation have resolved to continue promoting high-value care by reducing waste and overuse in health care in 2015. As such, we’ve launched the second Teaching Value and Choosing Wisely Challenge to identify the most promising innovations and bright ideas in medical education that can be successfully implemented on a larger scale.
We all talk about “patient-centered care” without having a clear vision or definition of what it is or means. Thus I was honored to have the ABIM Foundation be one of the many organizations the Gordon and Betty Moore Foundation and the American Institutes for Research (AIR) convened to develop a roadmap for patient and family engagement in healthcare practice and research. This work will help pave the way for true patient-centered care for the future.
A section of the tabloid, US Magazine, called “Stars – They’re Just Like Us”, shows pictures of celebrities doing mundane activities like walking the dog or taking out the garbage. This helps to remind us that, just like the average Joe, they walk their dogs and take out the garbage and— because they are people, too—might even need medical treatment from time to time. Unfortunately, some doctors treating celebrity patients don’t see them “just like us.”