Thursday, February 27, 2014

A Wasteful Week

     I'm a bit of a backseat driver these days. As a result of the economy and the number of people who have lost insurance (and gained Medicaid) we're seeing a lot of new patients who previously had commercial insurance plans and were being seen by community providers that do not accept Medicaid. Some of them reluctantly come to our resident clinic, but the majority are very grateful for the opportunity to receive excellent comprehensive care from our well intentioned trainees during a difficult transition in their lives.
I've never really worked as a private practitioner in the community, but this influx of patients switching to our clinic has given me some (albeit very limited) perspective on the care they receive in the community with commercial insurances. For the most part, everyone receives excellent care and they often express disappointment that they have to leave their long standing doctor. But on several instances, when we investigate their past medical histories, we've been seeing several instances of what appears to be wasteful unnecessary care.

In 1 week, here is a sampling of a few of these cases.

1: Middle aged gentlemen in good health, well controlled high blood pressure and some family history of heart disease was getting yearly stress tests because " My doctor  was thorough and wanted to be sure."

2: Gentleman who got his first colonoscopy at age 47 because according to his wife "We had really good insurance."
3: Twenty something  year old female, with mild occasional anxiety was getting yearly EKG's as part of her "Annual Exam."
I know I'm looking at these cases as a backseat driver. Perhaps I was getting an incomplete history and there were good reasons why these tests were ordered. But my instincts, medical knowledge and perspective on our current healthcare system suggests it falls under the category of wasteful care.
Reuter's Report on Healthcare system waste 2009

We are all guilty of practicing wasteful care and it's a multi-factorial problem. It start's by changing our mindset towards healthcare by looking at things in terms of value. We also need to make a concerted effort towards following the evidence, and when the evidence is overwhelming, use validated clinical decision support tools.

Case 1: See number 2. Choosing Wisely (American College of Cardiology)
Case 2: USPTF Colon Cancer screening guidelines
Case 3: Rethinking the value of the annual exam

We also have to hold each other accountable for these problems, and sometimes that means being an annoying backseat driver with a computer and a blog :-)

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Monday, February 17, 2014

Wegener's and Wikipedia on a cold winter morning, 2008

     The year was 2008 and I had a real swagger about me. After another long Philadelphia winter, the calendar was about to flip to March and spring. More importantly, the end of my internal medicine residency was within reach. It seemed like every day, I was doing something else for the last time. My last admitting shift, my last ICU rotation, my last 30 hour call. These were the many little aspects of a grueling residency that seemed so terrible at the time, but today is a memory I'm proud of.
     I carried that same swagger into my last morning report presentation. A miraculous catch by David Tyree and a Super Bowl victory by my New York Giants gave me the confidence to present my case with ease despite an audience full of Philadelphia Eagles fans. I presented a case about a gentleman that I had admitted for acute renal failure from Wegener's Granulamatosis. It was a great case that generated a lot discussion between students, residents and faculty. I concluded my presentation like others by reviewing some of the evidence and literature for its treatment. With my last PowerPoint slide, I paid homage to my interests in medical history by revealing the onerous story behind the gentleman for whom Wegner's was named. German pathologist Friedrich Wegener apparently had ties to the Nazi regime.
     My digression into medical history was well appreciated. It was a welcome break from discussing antibodies, drugs and the pure science of my case. I looked across my audience and started to notice eyes perk up as the decibel level in the room slowly increased while my presentation neared its end. I concluded my digression about the infamous Dr. Wegener by displaying my reference. It wasn't a journal or a textbook. It was "Wikipedia, The Free Encyclopedia that anyone can edit."
     My reference was met with a variety of reactions. There were those who looked confused and probably had never heard of Wikipedia. But there were those who laughed and found the reference humorous or perhaps comical. I wasn't surprised by the laughter or snickers. My residency and its faculty prided themselves in the strong academic traditions of evidence based medicine. Some residents even hesitated to cite established resources like The Washington Manual or Up To Date because it wasn't JAMA, or NEJM or Annals. I suspect back in 2008, a reference to a quirky online fad where any Joe or Jane could pose as an "expert" had little or no place in the halls of medicine academia. But as far as I could tell, the world was changing.
    Wikipedia is obviously not a fad. It is rapidly becoming the go to reference for everyone. Since 2008, the number of articles on it has doubled to 32 million, 4.5 million in English. Back in the day, I had a 25+ volume edition of the encyclopedia Britannica. I used it for all my school projects and I never questioned its authenticity. I never checked up on its references. I accepted it as truth and it got me through my academic life until Wikipedia. Modern education systems are and should rely on Wikipedia as a vital information resource just as I did with Britannica. In my opinion, Wikipedia is a monumental leap forward in civilization since it has democratized knowledge by taking the price tag off of it and allowing every citizen to contribute. One could even argue, it is everyone's civic duty to contribute to Wikipedia, just as we expect everyone to pay taxes or perform jury duty.
   In medicine we love our traditions and the knowledge that we guard is sacred. We also have a very high standard for the quality of that knowledge. It's part of the reason why we will probably be the last to accept Wikipedia as a legitimate source of information. But it's already happening whether we like it or not. In my own social media study at my institution, nearly all the students who responded are using Wikipedia for both personal and professional reasons.

Social Media in Medical education student survey, Blog Post

In my day to day work with residents and students, Wikipedia is a fast, quick reliable source of pulling up a variety of types of information. I find it especially useful pulling up basic sciences information (anatomy, biochemistry, physiology etc) which is often forgotten in the fast paced clinical real world.

I think medical academia is finally understanding that we cannot hide from the digital world and that we should understand it, participate in it and help shape its future. The University of California in San Francisco medical school is embracing this.

UCSF First US Medical School to offer credit for Wikipedia articles.

The Cochrane collaboration will also be partnering with Wikiproject  Medicine to help advance this movement.
Cochrane + Wikimedicine

These are just a few examples of how medicine is embracing something like Wikipedia and the body of literature supporting it is rapidly growing. It is part of the ongoing evolution of medicine as it looks to reshape its concept of knowledge and in the process better meet the educational needs of the next generation of physicians.

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