Starting With Curious

There are two especially awkward phases of life for most physicians: adolescence and residency.  Both are sort of in-between states, where you are not quite what you left behind but not yet fully what you are moving toward.  Is a resident a learner or a worker?  Depends on who you ask, and the answer has changed over time.  For example, when I was a resident we belonged to a union (!) – the Committee of Interns and Residents (CIR).  Except the CIR wasn’t a true union, because we were considered students rather than employees, and therefore not able to unionize.  At the same time, we were able to continue to defer payments on student loans because we were still “in school.”  Since then, the National Labor Relations Board has ruled that residents are actually employees and therefore entitled to organize (the CIR is now affiliated with the SEIU), while the IRS has ruled similarly, and residents must begin making student loan payments.  Win some, lose some.

The uncertainty carries over to the issue of federal funding for graduate medical education.  Currently Medicare, Medicaid, Veteran’s Affairs, and the states pay approximately $16 billion annually to hospitals to offset the cost of having residents and fellows.  Part of that covers the salaries and benefits of the trainees (direct GME), while the majority offsets the additional costs associated with medical training (indirect GME), such as lower productivity for supervising physicians, additional testing ordered by trainees, etc.  (I should note that this generally does not include pediatric residents and fellows, as children’s hospitals do not treat Medicare patients.  A separate, much smaller [$265 million] stream of Children’s Hospital GME funding is available, but unlike the Medicare money, it must be approved annually during the budget process.)

The rationale for this funding is that the training of physicians benefits society.  Teaching hospitals would have no financial incentive to train physicians who can, after all, go work anywhere when they are done.  Therefore, government should help pay for ensuring a supply of trained medical professionals.

Buried in a recent Institute of Medicine report on the state of graduate medical education, a small but notable group of health economists questioned that rationale.  They argue that residents provide a greater economic benefit to their hospitals than the salaries they receive; therefore, government GME funding is simply a subsidy of those hospitals.  The fact that most hospitals actually have more residents than they get funding for (the number was capped in the 1990s) is evidence that the hospitals must see them as a good investment.

If true, this might argue for using that $16 billion for other purposes, as those economists urge.  However, as I’ve already indicated, it’s not all that clear cut.  It is true that residents provide work that is of benefit to the hospitals that employ them as well as to the attending physician staff.  But much of this work takes the form of documenting and performing other tasks that can be – and in non-teaching hospitals, is – done by nurses or advanced practice providers.  And it isn’t clear that the work done by a resident provides more value than what could be done by these others, as the economists imply.  For one thing, residents rotate to different areas of the hospital each month, and often between hospitals.  There is a constant learning curve that in most cases sharply limits the benefit of the work compared with what you would get with a stable staff.  Moreover, the ratio of useful work increases with years of residency, but once residents enter their last (and most “productive”) year of training and really hit their stride, they leave.  In simple economic terms, most hospitals would actually be better off hiring non-residents for those tasks.

I do believe there is a unique value to a hospital of having physicians-in-training.  It’s not, as these economists argue, cheap labor.  Rather, it takes the form of the academic, intellectually challenging and stimulating environment that residents create.  It’s part of the reason I and many of my colleagues have always wanted to be at a teaching hospital.  That, however, is difficult to quantify.  In the current health care environment, with ever greater economic pressure, hospitals may be less willing to invest in such an intangible benefit without the GME funding.

Also, while it may be partly coincidental, teaching hospitals tend to be the care provider of last resort in a community.  The mission of caring for everyone regardless of ability to pay tends to go hand in hand with the education mission.  Part of the indirect cost of a teaching program is the large percentage of patients for whom the actual costs of care are not covered (Medicare, Medicaid, uninsured).  Yes, it’s a subsidy, but not for the bottom line of the hospital.  It’s a subsidy of the safety net we provide, masked as a subsidy for training future physicians.

There are certainly improvements we can make in the way GME is paid for.  For example, the program could do a better job of prioritizing undersupplied primary care fields (including pediatrics).  But arguing that GME funding is a form of corporate welfare for hospitals, and that the costs of training residents should be left to the marketplace, is not going to get us more of the right kinds of doctors, or better care for patients.

A neurosurgeon, a minister, and a nurse walk into a bar…. (There’s no punch line, though I invite suggestions for a good joke.)  I’m willing to bet that in picturing the scenario the vast majority of you imagined two men and a woman.  I’d even go so far as to say that the woman was the nurse.  It’s an example of how our thinking is influenced by our most recent experiences.  If you work at Children’s Hospital of Wisconsin, the last nurse you met was very likely female, and the last neurosurgeon was certainly a male.  It is what is referred to in the psychology of decision making as the “availability heuristic”: when we make judgments without complete information, we tend to refer to our most recent experiences, relying on the information we have available by easy recall to fill in for the information that is missing.  (A heuristic is a mental shortcut – there are many types, this being just one.)  Not knowing the sex of the characters, I draw on the most recent prior information I have about the sex of a neurosurgeon or a nurse.

Short cuts like this evolved as a way for our minds to function more efficiently.  When asked “Think of a common man’s name that starts with P,” it is far easier for me to conjure up the last man with that name that I interacted with (Peter) than to call up in my mind the complete list of men’s names beginning with P (Paul, Philip, Patrick, Pedro, Pradeep, etc.) and thinking about how many people have each of them.  In many circumstances, the availability heuristic works well and allows us to act on incomplete information.

You could argue that it’s simply a matter of playing the odds.  In the US, the majority of neurosurgeons and ministers are men, and the majority of nurses are women.  But research shows that we actually are not all that good at thinking statistically, and that playing the odds is often trumped by recent experience.  When recent experience is not representative of reality, this mental shortcut leads to bias.  For example, we recently had a patient in the ED who had just arrived from Liberia with high fever and upper respiratory symptoms.  Which is the most likely diagnosis: a) malaria, b) a cold, c) Ebola?  If Ebola even crossed your mind then you are displaying the availability bias; a cold is several orders of magnitude more likely based on actual prevalence.

Non-representative recent experience can steer us wrong in many ways.  It’s a common problem in medical diagnostic decision making, especially among non-experts.  I remember as a fellow seeing a teen with severe abdominal pain, to the point that he was irrational.  I had recently read about acute intermittent porphyria, which can cause abdominal pain and altered mental status, and promptly ordered a urine porphobilinogen level to test for it.  Never mind that it has an incidence of around 1 in 50,000.  Not only was I wrong, it delayed me from treating his pain and making the actual diagnosis (kidney stone, incidence about 1 in 10, though less common in teens).  I suspect the availability bias explains a good deal of the higher cost of care provided by medical trainees.  The first time a resident sees someone with a rare illness, they start to evaluate more patients for that problem.  It’s also a culprit in driving some utilization by patients.  When the media run sensational reports about uncommon conditions, people overestimate their risk and often seek unnecessary medical care.

The availability heuristic also leads to broader bias in society.  For instance, young blacks are arrested for marijuana possession at much higher rates than young whites, despite having a similar frequency of drug use.  Blacks thus have higher rates of incarceration, and news stories about drug arrests are much more likely to feature African-Americans.  As a result, people (both blacks and whites) overestimate the proportion of criminals that are black.  In one study, 60% of viewers of a crime story without a picture of the suspect falsely recalled seeing one, and 70% believed that the suspect was African-American.  After all, the last news story they saw about crime was likely to have featured a black suspect: availability bias.  Similarly, low income individuals are more likely to be prosecuted for child abuse, leading us to believe – incorrectly – that those who are more well off are unlikely to maltreat their children, and potentially missing an opportunity to intervene when necessary.

There are many examples of how our use of this mental shortcut can lead us not only to misrepresent how common or uncommon something is across a group, but also to misapply the most readily recalled information about groups to individuals.  Even when the most recent image is truly representative (e.g., most nurses at Children’s are female), it may not apply to a given individual.  (Just ask any of the 3 male nurses I worked with in the ED yesterday!)

The availability heuristic is just one of the filters we all see the world through.  Like other filters, it’s not necessarily either good or bad, but it is something to be aware of.  When we make a snap judgment without having all the information, we need to be aware that we are overly influenced by our most recent experience and by the way things are portrayed – correctly or not – in society at large, and be willing to reshape our initial image as we get more information.  And while some people cry “political correctness” when we use gender-neutral language or multiracial images, a non-biased environment is an important way to make our mental images more accurate.  I know more than a few women neurosurgeons, female ministers, and male nurses who would appreciate it.

I’m overdue for one of the rituals of middle age in 21^st century America: the screening colonoscopy.  Now this may have been a rationalization, but just after my doctor referred me for one, I changed employers, and therefore insurance plans (moving into a high-deductible plan), so I needed to see what the coverage would be.  Of course, it’s taken me 2 years to do it.  Can’t read the fine print too carefully, I always say.

Turns out, I’m not atypical.  A study in Medical Care looked at people who were switched from an HMO to a high-deductible health plan (HDHP).  Compared with those who stayed in the HMO, people in the HDHP tended to use fewer low acuity services (such as non-urgent ER visits).  Interestingly, women had similar rates of use for medium- to-high acuity services, while men reduced their use across all levels of acuity.  It appears that women are better health consumers than men, wisely saving resources for services that are more necessary.  Men are either just cheap, or looking for an excuse not to go to the doctor.

There are many myths and uncertainties surrounding HDHPs.  More and more Americans are enrolled in them – including an increasing share of employees at Children’s Hospital of Wisconsin – so it’s worth addressing a couple of those.  First, preventive care (including, if it’s coded right by the provider, screening colonoscopies) is generally covered at 100% and not subject to cost-sharing.  So don’t skimp on the check-up and vaccines; you’ve already paid for them through your premium.  Second, research has shown that for most people, HDHPs lead to more rational use of health resources (that is, avoiding unnecessary treatment while preserving needed treatment), with no worse health outcomes compared with forms of insurance that do not require the patient to bear as much of the cost.  There is an important exception: the RAND Health Insurance Experiment showed that lower income people deferred both needed and unneeded care similarly, and had some worse health outcomes associated with that.  (And maybe stubborn men, as well.)  That said, making good choices requires some guidance.  It’s not necessarily easy for people without medical training to distinguish low-value services from those that are necessary.  A key principle is to ask questions.  Is a brand name drug necessary, or would a generic do?  Or what about no medication at all – would the condition get better on its own?  How will doing a diagnostic test change what the provider will recommend in terms of treatment?  There are many sources of information on line, many of which are of dubious quality.  A particularly reputable one is Choosing Wisely, where you can find recommendations from the leading medical professional organizations about services that are generally agreed to be low value.

When used well, high deductible plans are nothing to be afraid of, and may have the potential to decrease costs with as good or better outcomes.  I guess the same is true of colonoscopy….

My older son spent the first year and a half of his life in Falls Church, VA.  Based on data from the Robert Wood Johnson Foundation, his life expectancy is 83 years. (Don’t worry, buddy – they go fast but you have plenty left.)  But if he had been born three Metro stops away, in Washington, DC, his life expectancy would be 7 years shorter.  The situation is even more striking in New Orleans, where the difference in life expectancy across the metro area is 25 years.  As an article in Health Affairs put it, Zip code is more important than genetic code when it comes to health.

It’s easy to write this off.  Different communities, different people.  While there are undoubtedly differences in population between neighborhoods – including racial and ethnic differences that may include a genetic component – the strongest association is with poverty.  Poor people have worse health regardless of their race or culture.  Moreover, a 2011 study published in the New England Journal of Medicine showed that when people who began in a poor neighborhood were randomly assigned to receive housing vouchers allowing them to relocate, those who moved to low-poverty areas subsequently had lower rates of obesity (19% lower) and diabetes (22% lower) than those who either stayed or moved to another high-poverty area.  It appears the real estate people are right: it’s all about location, location, location.

The exact factors about a neighborhood that lead to adverse health impacts are unclear.  Possibilities include: physical infrastructure (e.g., parks, sidewalks, safe streets) that allows and promotes physical activity; access to healthy food; low crime and attractive environment that decrease chronically elevated levels of stress hormones.

As an organization committed to making the children in Wisconsin the healthiest in the nation, Children’s Hospital recognizes that we can’t simply provide excellent health care.  We must partner to influence all the other determinants of a child’s health, including the state of their community.   A recent article in the New York Times highlighted a Philadelphia program of community health workers: individuals from target communities, hired by a health system and trained to work with other families in those communities to address health needs and connect with needed resources.  This is very similar to Children’s’ own community health navigator program in three neighborhoods in central Milwaukee.  Health Partners, an integrated health system in the Twin Cities, has adopted what it calls a “community business model,” whereby they invest in activities and partnerships that are designed to improve all of the modifiable determinants of health, not just medical care.

Kids on the near north side of Milwaukee deserve to have the same life expectancy as those in Wauwatosa.  To get there, it truly takes a village.