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In last week’s New York Times article by Elisabeth Rosenthal, “Patients’ Costs Skyrocket; Specialists’ Income Soar,” we read about the plight of Kim Little, who lives 30 miles from Little Rock, Arkansas. She felt like a hostage when she was told she needed plastic surgery for the removal of non-cancerous mole instead of just a few stitches. She protested unsuccessfully against having the procedure. Her preferences were ignored because the protocol, according to her medical group, dictated otherwise.
At the 2011 ABIM Foundation Forum, Don Berwick gave a powerful talk on reducing waste in health care spending by targeting “wedges.” The wedges concept comes from environmental science research on reducing the trajectories of carbon dioxide levels over time. In their study, researchers concluded that there is no one magic solution–the problem must be tackled by addressing a number of discrete wedges that will collectively have a major impact.
The wastefulness of unnecessary EKGs is a subject that has been featured on this blog many times before, both by me and Dr. Stephen Smith, and a topic that has recently been highlighted in multiple Choosing Wisely ® lists.
When I was recently told I needed surgery for cataracts, I was sure I wouldn’t need a third preoperative EKG. The two I had previously were performed prior to the American Academy of Ophthalmology (AAO) and the American Society of Anesthesiologists (ASA) lists of recommendations, which state:
- “Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/ esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.” – ASA
- “Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.” – AAO
So when I was forced to get another EKG or abandon the surgery, I wasn’t going to let it lie. I felt empowered and well-informed by the backing of these two world-renowned specialty societies. Before the surgery, the anesthesiologist, Dr. B. (who turned out to be the Director of Anesthesiology) and I had a little chat:
The start of a new year marks the kickoff of the ABIM Foundation’s annual Professionalism Article Prize selection process. As the staff person in charge of compiling the previous year’s professionalism articles, this project gives me an opportunity to see the depth and breadth of the professionalism literature. We are in our fourth year of awarding the prize, and it is gratifying to see how the literature keeps growing as we continue to understand how to define, educate for, support and assess professionalism. Below are a few topics from 2013 that I hope are given further attention from researchers this year:
Every time I am invited to speak about the Choosing Wisely campaign, I ask the audience to raise their hands if they have witnessed or heard of unnecessary care delivered to patients, themselves and/or their family members. Usually, about three-quarters of them raise their hands. I then ask if they have witnessed or heard of cases where someone was harmed by unnecessary care and about a quarter still have their hands raised. Why do we hear more stories on misdiagnosis as a result of tests that were not ordered and not the stories where unnecessary tests caused harm? Sharing such anecdotes is an important component of increasing awareness of wasteful tests and procedures.
Since its launch in April 2012, the Choosing Wisely® campaign’s focus has always been on the conversation between physicians and patients about overuse and tests and procedures that may often do more harm than good.
Trying to change the public’s mind that more care does not always equal better care is a huge challenge. Short visit times, advertising about the latest and greatest techniques, and patients armed with self-diagnoses from online research don’t make this challenge any easier. As such, the Choosing Wisely campaign funded Drexel University School of Medicine—a leading medical educator in patient-physician communication with decades of experience in teaching interview skills—to develop modules to support the campaign. The resulting modules help physicians hone communication skills that facilitate discussions around unnecessary care and the concept of stewardship with their patients.
“There are many mechanisms for paying physicians; some are good and some are bad. The three worst are fee-for-service, capitation, and salary.”
I first heard the above quote (attributed to health services researcher James Robinson) several years ago at a Foundation meeting on payment reform. While meant to be humorous, I often think of this statement when reading about payment reform proposals to remind myself that:
- there is no perfect compensation system; and,
- whatever system we choose sends important signals about what we value.
Many criticize our current, primarily fee-for-service system, for rewarding volume of care, and ask how we can change health care payments to instead reward high-value care. As a PhD student in public health, I definitely appreciate the contributions of primary care to the health of populations, but how can we assure that payment systems recognize the value of primary care?
After graduating from college, I spent a year as an AmeriCorps volunteer at a Philadelphia-area clinic. Living on an AmeriCorps stipend is challenging, so I looked forward to the days when drug reps came to the office bearing pizza or sandwiches. I rationalized taking the lunches and occasional pens and sticky notes. Money was tight and I couldn’t prescribe medications, so how could it influence me?
I left this year’s Association of American Medical College’s (AAMC) annual meeting, inspired by AAMC President and CEO Darrell Kirch’s speech about “defining moments” in medical education and training. As I exited the Philadelphia Convention Center, I was approached by a medical student passing out 3×4 cards that said:
Meet a Philadelphia Eagles Player
Visit Booth XXX
XXX Medical College
I am going to confess something that may make me a pariah in the land of Eagles madness, not to mention among all of the fantasy football enthusiasts in our office.
I don’t like football.
Call me uptight, but it’s hard for me to kick back and enjoy a sport that causes significant brain damage in many of its players. Clearly, however, mine is a minority view. Professional sports such as football are big businesses that generate billions of dollars in annual revenue and have a profound influence on our culture.