Medical Students Write Handbook for their Peers

Elisabeth Askin is a third year medical student at Washington University in St Louis and co-author of The Health Care Handbook for medical students.

In 2008, I volunteered at the San Francisco General Hospital Emergency Room, enrolling patients in research studies. One study correlated clinical signs in trauma patients with positive findings on chest x-rays, so that orders could be better informed and more efficient. And efficiency was certainly needed - I was stunned to learn that only 3% of trauma chest x-rays yield positive results. That’s a lot of time, money, and energy for very little useful information.

We may not doubt the judgment of those ER physicians, but we also know that each clinical decision has an effect on the national bottom line. Health care costs in the U.S. have reached 17% of GDP and continue to rise. Everyone agrees that our current situation is unsustainable and that change is necessary.

Cost is not the only way that the individual, daily behavior of providers and patients combine to form a larger picture. Obvious examples include rising antibiotic resistance and defensive medicine. Less obvious examples include off-label prescribing and the obesity epidemic. Whether we recognize it or not, all of our actions are affected by – and in turn affect – larger societal trends.

Thus, the question is: how do we combine doing what is best for each patient with understanding our role in the larger picture?

For one thing, we need to have an idea of what that larger picture is. Medical students not only don’t know about prices – they often aren’t familiar with the most basic aspects of health care delivery, policy, insurance, economics, drugs & devices, or reform. It’s not because of a lack of interest but rather because getting a view of the larger picture isn’t easy.

The news and blogs provide a ton of details without the scaffolding to connect them. Popular books often provide one-sided arguments. And scholarly books mostly offer highly detailed knowledge about solitary aspects of the system – which may obscure the forest in favor of a leaf. Meanwhile, schools usually only expect us to know that Medicare covers the old while Medicaid covers the poor.

Students shouldn’t have to work hard to cobble together an understanding of what an HMO is, how an NP differs from an RN, or what the options are for the uninsured. While trying to learn these things on my own, I found myself wishing for a dummies’ guide or a single reference, but to no avail. So a fellow medical student, Nathan Moore, and I decided to write our own.

The Health Care Handbook: A Clear and Concise Guide to the U.S. Health Care System introduces the key facts and foundations that make the health care system work. The book includes balanced analyses of current challenges and controversies in health care, including medical errors, government regulation, medical malpractice, high drug prices, and much more. And, no surprise to anyone reading this site, we devoted an entire chapter to insurance and economics.

Medical students, residents, and attendings should know how much a chest x-ray in the ER costs, but that’s not all. They should also know how few trauma chest x-rays show any findings, how little care in the ER gets reimbursed, that hospitals are building new cardiology wards to offset those costs, and what kind of testing the new devices in the cardiology wards have to go through.

We need to make sure that our behavior, while always determined by the patient in front of us, rationally and practically acknowledges the system in which we work. Those of us in medical school now know this will play larger role in our careers than it ever has before. It’s time to start asking for more education about it.

The New Generation of Medical Students

The following post  is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard

We are a new generation of physicians and physicians in training.  The words “stem cell therapy”, “Robertsonian translocation” and “artificial tracheal transplant” were part of our vocabulary from the first day of medical school.  At the astounding speed at which scientific advancements are made, our ability to incorporate new material is in a constant state of change.  Slowly, the heavy textbooks became relics, as we migrated towards a mobile knowledge, a way for us to carry around and receive up to date medical information at any time or place of the day.  We became the generation of iPhones and iPads, the generation who is satisfied with the ability “know where and how to find the information”, painfully aware of our inability to memorize and keep up with everything.

But in spite of the growing fluidity of the medical curriculum, it was baffling for most of us to enter the “real world” of hospitals and clinics and realize how little we knew.  While we were quite familiar with the Krebs cycle, electrolyte imbalances, rare genetic mutations, the “high-tech” seemingly comprehensive medical school curriculum stopped short. During our clinical years, we realized that our knowledge of pathophysiology was dwarfed by our unawareness of the issues that are so saliently engrained in the lives of our patients.  Not a single medical student knew what a complete blood count test would cost, or how much a patient would be billed after a night in the intensive care unit. Yet, we took pride in knowing how to enter an order in the computer and interpret an abnormal test.  We were naïve to think that our patients are “non-adherent” to medications, when in reality, they just couldn’t afford them and were too embarrassed to admit it.  These issues were foreign to us.

The definition of a “good physician” has changed in the last few years.  It is no longer sufficient to limit ourselves to medicine; we must learn to take a holistic approach towards helping our patients, and this includes a keen awareness that our best medical care could mean their bankruptcy.  In the last few years, physicians started to recognize “pain” as a 5^th vital sign, in addition to temperature, heart rate, respiratory rate and blood pressure.  Perhaps it is time to consider “ability to pay for medical expenses” as a close-up runner to our list of vital signs, one that could easily increase your heart rate and make one short of breath. 

We are a new generation of physicians and physicians in training.  And our vocabulary ought to include words like “cost-awareness”, “cost-efficiency”, and “cost-reduction”.  At the astounding speed at which medical costs are increasing, our minds are thirsty for more knowledge, more skills and more wisdom at how to truly become a physician of the 21^st century.

A recommendation to minimize costs backfires

The following anecdote is by Alexis Ball, the daughter of a patient from New Mexico. Her story was originally submitted to the 2011 Costs of Care Essay Contest.

My mom passed away last December to Stage V breast cancer metastasized to her liver. During this battle she developed ascites (an accumulation of fluid in the peritoneal cavity) as her liver failure progressed. This accumulation of fluid was not only extremely uncomfortable but painful as well. In an attempt to find symptomatic relief for the last months of my mom’s life, the oncologist presented us two options: we could come in to clinic weekly and be tapped to have the fluid drained or we could implement a permanent drain in her peritoneal space.

Per the doctor’s advice, we opted for the latter option. The doctor recommended this option because my mom was on blood thinners and this plan obviated the need to continually reverse her Coumadin dose. Thus this equated to less time for her in the clinic and was less expensive for the hospital and our family… or so we all thought.

Our insurance company approved the top of the line specialty drain for this procedure. After the procedure, the hospital provided us with the first batch of drainage supplies. My dad and I learned how to properly drain my mother and change her dressings. We got into a routine of draining every night before bed. There was a dramatic improvement in my mother’s quality of life due to the release of extra of pressure in her abdomen. All was copasetic until it came time to reorder our supplies,

“Hello Ms. Ball! I understand that you are reordering the drainage and dressing kits , unfortunately they are out of plan for your insurance”

We were dumbfounded. How could the insurance cover a system in which they did not support the supplies?

“These are non durable goods and not covered. The cost of the kit will be 600 hundred dollars monthly with a deductible of 750 for the first month”

Our jaws dropped.

Due to my mother’s illness she was no longer working and was waiting to receive disability benefits. Six hundred dollars a month was more than a third of her entire income on disability. Our oncologist was horrified to learn that the nondurable goods associated with the drain were not covered. He had no idea that this was the case. Our doctor had recommended this plan to not only reduce chances of infection but also minimize costs for our family. This knowledge would have altered his recommendation of treatment plan for our family.

Yet it gets better, the drainage system leaked, requiring dressing changes two to three times a day. These extra dressing changes increased our out of pocket expenses by two fold. The cost of maintaining this system was extremely prohibitive. We could either afford to pay our bills or pay for the supplies of this drainage system. Thus, we resorted to using non sterile dressings instead of the prescribed dressings. Our replacement dressings included sanitary pads, urinary pads, saran wrap, and the occasional paper towel. Although these means were clever and much more cost friendly for us, they greatly increased my mom’s chances of a peritoneal infection. A peritoneal infection would have resulted in a hospital stay and a much more costly bill for both our family and the insurance company than the sterile dressings my mom needed. My mom always joked that the solution to our financial struggles with medical care costs was for her to just hurry up and die… which much to a young daughter’s dismay was the heartbreaking truth of our situation.