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Leaving against medical advice calls for an honest conversation

Posted by Ishani Ganguli February 27, 2014 07:00 AM
His nurse paged me at 9 p.m.: Mr. L wants to leave against medical advice (AMA). As the covering doctor, I dreaded the impending standoff even more than usual. 

I emerged from the elevator minutes later to find that the gaunt octogenarian had advanced from his isolation room, passed the nurse's station and the unit doors, and arrived at the elevator bay to greet me. Security guards hovered at a cautious distance as I met his eyes. 

"Hi sir. I understand you’d like to leave?" 

He spat his response like chewing tobacco from his blood-crusted lips: "They changed my room. I’m tired of this place. I just gotta do something at home." 

Mr. L had come to the hospital after months of coughing, weight loss, and difficulty swallowing. The list of possible diagnoses was long, with cancer and tuberculosis in the lead. But he was not at all interested in staying to sort it out.

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Teach Medical Students How To Be Placebos

Posted by Ishani Ganguli January 17, 2014 12:07 AM
Enjoy this guest post from Karan Chhabra, a medical student at Rutgers Robert Wood Johnson Medical School and co-founder of the blog Project Millennial. Connect with him on Twitter at @krchhabra.

Placebos work. This isn't news. The term "placebo" was coined 60 years ago to describe how one-third of people respond to pills without any active drug in them. Twenty-five years later, we learned how they work: through endorphins produced by the body that work just like morphine. Today placebos are everywhere: from mothers kissing boo-boos to international drug trials. 

A recent paper, though, shows that all placebos aren't created equal. As expected, the authors found placebo pills effective for reducing migraines in about one-fifth of patients. But it gets better. Take sham acupuncture, which doesn't target traditional pressure points and doesn't penetrate the skin. Despite being "fake," sham acupuncture reduced migraines in 38% of patients, making it as effective as real migraine drugs. The authors also studied sham surgery, in which doctors give anesthesia and cut the skin, but stitch it back together without doing anything to the tissues underneath. These fake operations helped 58% of migraine patients, potentially even more than active drugs. 

What does this tell us? It depends on whom you ask. Some might say we need to figure out how to predict a good response to placebo (and are trying to do just that). Others might say we need to test more procedures against shams, to make sure they're effective. Yet others might say sham surgery is unethical outright. These are questions without quick answers. For the rest of us, what can the placebo effect teach us about medicine as a whole?

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In the New Year, a new mom in medicine

Posted by Ishani Ganguli January 7, 2014 07:00 AM
Months before my life was upended, a doctor friend tried to explain my forthcoming role in terms I'd understand. "Imagine being on call 24 hours a day, seven days a week," he said. "You're in charge of a single patient, but she is needy as hell." 

Medical training prepared me for motherhood in some ways (the assortment of facts blurrily retained from my pediatrics rotation in medical school; the skill, or delusion, of combating the inertia of sleep), but not at all in most others. And now, after two months devoted to tummy time and 5 a.m. staring contests with my sweet, saucer-eyed baby girl, I join the ranks of countless men and women attempting the uneasy balancing act of work and parenthood. I'm doing so at a time when the terms of re-entry for new mothers into medicine seem particularly disputed.

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Doctors crowdsourcing primary care

Posted by Ishani Ganguli December 10, 2013 07:00 AM
Be it a borderline-worrisome electrocardiogram, a constellation of symptoms that defies a unifying diagnosis, or a laboratory result that is unexpectedly out-of-whack, all questions lead to the Bauer Room - the workspace for internal medicine residents at Massachusetts General Hospital that has come to be synonymous with getting a second opinion. (Other uses include griping about work and getting rid of an oversized batch of baked goods). 

This congress of our peers, each of us off to a different branch of internal medicine, offers the power of collective wisdom and specialized knowledge as well as the safety to test out theories in a relatively judgment-free zone: How would you approach this patient? Am I missing anything? Some would say that we learn as much through conferring with our co-residents in the Bauer Room as we do in our daily lunch conferences.

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The next surgeon general?

Posted by Ishani Ganguli November 15, 2013 09:45 AM
Last night, I learned of President Obama's plans to nominate Dr. Vivek Murthy for the position of Surgeon General: America’s chief health educator. I have the pleasure of knowing Vivek through several mutual friends as well as by reputation and I'm thrilled about the choice. Vivek is a hospitalist at Brigham and Women's Hospital and the Co-Founder of Doctors for Obama, a grassroots organization of physicians and medical trainees that worked to campaign for the president during his first election. In 2009, Vivek re-launched the group as Doctors for America (DFA) to advocate for better health care access, affordability, and quality - in part by promoting the Affordable Care Act; DFA now comprises more than 16,000 doctor and medical trainee members (including myself) in all 50 states. Through a public (and physician) education campaign that made use of speaking engagements, fact sheets, and personal stories, Vivek's group has sought to provide Obamacare with a much-needed public relations boost. His experience and success in this effort may now serve him well as the face of American health care (in lieu of healthcare.gov's Adriana) at a time when the ACA's public image is at a new low.

I know Vivek to be a soft-spoken leader who is sharply intelligent and incredibly sincere. He has long championed the notion that we doctors must advocate for the health of our patients. Though his path to Senate approval may be fraught with partisan rancor, I'm hopeful that he will soon embody and act on this principle as the nation's physician.

Paging the senior resident

Posted by Ishani Ganguli October 4, 2013 05:45 PM
Lately, I've spent a lot of time walking briskly around the hospital, two to three pagers clipped to my sagging scrub pants and a Code Blue checklist tucked into my back pocket for easy reference. I'm working as "Senior On" - one of the more defining roles of the senior medical resident at Mass General. During each two week block, six of us take turns responding to and leading the management of cardiac arrests and other medical emergencies throughout the hospital. 

I encountered the role during my first overnight call as a fourth year medical student, when the 80-something-year-old man with widespread lung cancer I'd met minutes before became unresponsive and triggered a call for the rapid response team. I watched with relief as the Senior On resident strode in, flanked by a pharmacist and nursing supervisor. As I breathlessly reported my patient's rapid decline and the resident calmly took charge, I wondered how I'd ever have the knowledge and confidence to fill her Dansko clogs. It has since become a matter of habit.

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"Expecting Better" from your doctors during pregnancy

Posted by Ishani Ganguli September 20, 2013 04:30 PM
Of all the pregnancy taboos I've heard in my 34 weeks of this surreal, at times ache-inducing, but ultimately incredible state, caffeine has caused me the greatest chagrin. Strangers in line at Coffee Central offered helpfully: “You’ll get decaf, of course.” My four-year-old nephew looked at a cup of tea in my hands, his brow furrowed with reproach: “But you’re pregnant!” My obstetrician-gynecologist drew the line at one or two coffees a day. My personal literature review allowed me a more nuanced approach in which I count milligrams of caffeine per day, adjusting for my hydration level and professional obligations.

So when a few friends forwarded me an article in The Wall Street Journal by University of Chicago economist Emily Oster that purported to dispel myths of pregnancy and set the record straight on such divisive beverage choices, I was intrigued. I've since read her book on the subject and have come away with mixed feelings.

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Postcard from Las Vegas: The Iora Health model of primary care

Posted by Ishani Ganguli September 5, 2013 11:30 AM
Chidimma Ozor calls Valerie for their twice-weekly check-in. 

"How’s it going? How have your sugars been?" 

"Not great. I checked first thing this morning and the meter just said 'Hi.'"

"What did you eat for dinner last night?"

"Salad."

Chidimma perked up. "Green?"

"Potato."

"And otherwise?"

"Not so good."

Valerie feels dizzy. She can’t see right, she has no appetite, and she’s been vomiting for the past few days. Chidimma hands the phone to me and after a few more questions, I’m on board with the plan she’s communicating loudly with her eyes: bring her in.

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First, do no harm: Medicine in the Information Age

Posted by Ishani Ganguli August 22, 2013 07:00 AM
This week I’m thrilled to share a guest post from Karan Chhabra, a medical student at Rutgers Robert Wood Johnson Medical School and co-founder of the blog Project Millennial. Connect with him on Twitter at @krchhabra. 

Minutes from melting in the summer heat, I dumped my stuff at a table and homed in on the hospital café’s soda display for something - anything - cold. The gentleman at the next table glanced my way and said: 

"Are you in the medical field?" 

"Yes sir, I’m a medical student." 

He eyed my drink and asked, "Did you hear that diet soda can increase your risk of diabetes by 70%? Even just a few cans a week." 

"No sir, I hadn't heard that." 

"Seventy percent. Since then I've been drinking regular Coke. Wish I'd known ten years ago."

Sure enough, on his table was a bottle of regular Coke. And I was drinking diet. I’m not trying to lose weight; for me they’re just an occasional treat. I also far prefer the taste of diet, doubt me as you may. I wondered whether the gentleman had diabetes and was now blaming diet soda for causing it. I wondered where he'd heard that 70% figure, and of course I wondered whether that research was actually any good. Since it wasn't a clinical setting and he wasn't my patient, I didn't ask him any of those questions. But the trim, slightly disheveled gentleman in the hospital café certainly got me thinking.

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Your hospitalization, your story

Posted by Ishani Ganguli August 14, 2013 07:00 AM
Whether it lasted hours or months, every hospital stay is chronicled in that one final document: the proverbial baton passed from a patient's hospital doctor to his primary care provider better known as a discharge summary. 

This report has always been available to patients after they fill out a decent amount of paperwork. *In a few months, Massachusetts General Hospital will begin to share discharge summaries with all patients through an online portal. The move came as a surprise to many doctors, prompting discussion about the purpose of these summaries and the implications of sharing them openly. 

The intent of this new transparency, according to an E-mail from the hospital's Health Information Services, is to "help patients make healthier and more informed decisions about their care.”" Beyond the ethical argument that patients ought to have easy access to information about them (which is the norm in countries like France), there's a practical benefit to sharing discharge summaries. Knowing the specifics of your medical issues (say, that you have atrial fibrillation, not just "a funny heart rhythm") and of your hospital course, you're better-equipped for Google self-diagnosis. More importantly, you can be a resource and an advocate for your care when you see doctors down the road, especially if they don't have access to records from your previous providers.

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The art of self-rationing drugs

Posted by Ishani Ganguli July 31, 2013 11:00 PM
It wasn't so much the side effects - nausea and belly pain that had once kept me from enjoying my aunt’s home cooking. I didn't fill my prescription for the malaria prophylactic Malarone before a family trip to India because the $50 co-pay seemed outlandishly expensive to a medical-student-in-debt. Years later, I find that my patients skip crucial medications to treat diabetes and depression because of the reality or even just the fear of insurmountable co-pays. 

A 2012 survey of more than 1200 American adults by the Kaiser Family Foundation suggests that my patients and I aren't alone. Twenty four percent of respondents reported that they or their family members had neglected to fill a prescription because of cost in the previous twelve months. Sixteen percent admitted to cutting pills in half or skipping doses to extend a medication. 

Save for the opulent few, we all factor cost into our daily decisions and health care is no exception. This principle is the basis for not-so-new efforts by policymakers to give patients a larger stake in rising health care costs. If patients share a larger portion of their costs through mechanisms like coverage limits and higher deductibles, they might make more responsible use of these resources, the thinking goes.

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More prescriptions more problems

Posted by Ishani Ganguli July 23, 2013 11:00 AM
A 90-year-old woman comes to the hospital, like so many others, after a fall that leaves her skin bruised and her tailbone broken. The best thing we can do for her, besides managing her pain and getting her through physical therapy? Scrutinize her medication list. 

Polypharmacy - literally, many medications - is a diagnosis that disproportionately affects elderly patients. They are particularly susceptible to the mind-altering and dizzying effects of drugs like zolpidem (better known as Ambien, used for sleep), diphenhydramine (or Benadryl, an anti-histamine and sleep agent), and too-high doses of blood pressure medicines - with the consequence of dangerous, sometimes deadly falls. I spent my last week working with geriatricians as part of a primary care elective and found that the focus of most visits was, if not glamorous, then at least resoundingly consistent: reviewing medication lists and paring off such worrisome drugs.

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Sharing difficult decisions

Posted by Ishani Ganguli July 9, 2013 07:00 AM
In the New Yorker blog entry she posted last Friday, Lisa Rosenbaum wrote about a topic dear to my heart: shared decision making. It refers to doctors empowering patients to make medical decisions based on their values and preferences when there is more than one reasonable path. Many researchers have found that shared decision making (with the help of decision aids) leads to more informed decisions and may even lower health care costs

As Lisa points out, this approach doesn't apply to every decision or appeal to every patient. My parents, who grew up in India, feel they haven’t gotten their money's worth if their doctor cedes too much to their untrained judgment. Some of my co-residents have grown frustrated with repeated institutional reminders to use SDM, arguing that their patients don't have the education to weigh choices and make informed decisions, and that it's hard to make time for it in a short visit. I get these concerns. And like Lisa, I worry that codifying SDM in the Affordable Care Act may entice doctors to simply go through the motions.

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Cats on a plane, revisited

Posted by Ishani Ganguli June 21, 2013 07:00 AM
Soon after posting a blog entry on airplane medicine, I got an email from Jodi Larson, an Associate Director for my residency program and Assistant Chair at Newton-Wellesley Hospital’s Department of Medicine. Turns out, the cat story is true and she was one of its (non-feline) protagonists. 

A few details had been lost along the way: About ten years ago, Jodi was flying from Boston to her then job in San Francisco. Along with a pediatric resident from Children’s Hospital Boston, she answered the distressed call of teenagers who had chosen a cross-country flight for their house-cats’ first real world outing and had medicated them with Librium (an anxiety medication in the same drug class as Xanax and Ativan) to withstand the journey. The pediatric resident wouldn’t give up on the cat that had already died, so Jodi had to physically pull him off to focus on the one with a fighting chance. They did, in fact, place a breathing tube in the second cat before connecting with an on-ground veterinarian who guided them on cat-appropriate treatment to reverse Librium’s effects. Cat number two survived.

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Too little, too late: When medical technology fails

Posted by Ishani Ganguli June 10, 2013 08:30 AM
This week, I’m delighted to share a guest post from Dhruv Khullar, a joint degree student at the Yale School of Medicine and Harvard Kennedy School.

Lying in his hospital bed, he looked a lot like Santa Claus. A pleasant gentleman in his late 50s, he had a big beard and a big belly to match. He was a charming man - the kind that caregivers were drawn to and rejuvenated by. After a week of pre-rounding, we had developed a comfortable rapport and fell into a familiar routine. I would enter his room at 6 am to ask him about the night's events and perform a quick physical examination. Inevitably, he was already awake. 

"Isn't it a little early for you to be up, young man?" he would ask. 

"That’s why they pay me the big bucks," I'd respond, and we would share a smile. We both knew of the mounds of debt I was accumulating with each passing year of medical school. We also both knew that two of my last three meals had consisted of saltine crackers and diet Shasta that I "borrowed" from the nurses' station. 

Despite his jovial demeanor, he was a very sick man. He had been uninsured for most of his adult life and had sometimes gone years without seeing a doctor. Intermittent and disorganized care had left him with two major medical problems: a weak heart and poorly controlled diabetes.
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Is there a doctor on the plane?

Posted by Ishani Ganguli May 31, 2013 12:00 PM
Most doctors have a story about being called to assist with an in-flight medical emergency. I have yet to earn one for myself, but my favorite story - passed down from resident to resident - goes something like this: An airline attendant called for a veterinarian's help. When no one answered, they settled for a doctor and an anesthesiology resident stepped up. He learned that a passenger traveling with her two cats had given them Xanax to calm them during the flight and their breathing had grown worrisomely slow. As it turned out, one of the cats had already met her tragic end but the other still had a pulse. The resident found a pediatric medical kit and placed a breathing tube in the poor animal, leaving his owner to squeeze an oxygen bag to ventilate the cat for the remainder of the flight.

Trained health care workers have long been called to perform outside hospital or clinic walls (the Boston Marathon attack was a recent, poignant example). But there is something particularly dramatic about medical distress in an enclosed space miles above sea level and particularly momentous about the decision to divert an airplane carrying hundreds of passengers.

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Computers vs patients: A day in the life of a modern intern

Posted by Ishani Ganguli May 21, 2013 07:00 AM
If you're a medical intern, most of what you need to do your job can be pulled off a computer screen: Blood test results. Paged messages. Orders to start a medication. All but, of course, how sick a patient is. How he feels. What his rash looks like. 

Researchers at Johns Hopkins University and the University of Maryland, suspecting that more and more of an intern's time is spent in front of a computer, looked into just how today's intern spends her working hours on an inpatient ward. They asked trained college students to shadow 29 internal medicine interns from two different Baltimore teaching hospitals and document how much time they spent talking to patients, eating lunch, reading charts, and the like - for nearly 900 hours over the course of three weeks. Their recently published results confirm a trend that old-timers nostalgically lament and that those of us in training know to be all too true: only a small percentage of our time is spent in direct patient care.

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On hospital charges and doctors' decisions

Posted by Ishani Ganguli May 10, 2013 07:00 AM
How much to treat this pneumonia? On Wednesday, the Centers for Medicare and Medicaid took a step towards answering such questions by publicly releasing how much each of 3000+ U.S. hospitals charged Medicare for 100 common medical issues in 2011 and how much Medicare actually paid them. The charges were remarkably variable, even among hospitals that share a zip code. Massachusetts hospitals tended to charge below the national average (eg. for pneumonia with complications, $14,686 compared to $51,726 nationally), though teaching hospitals like mine were more expensive (Massachusetts General Hospital charged $49,883 on average for pneumonia with complications; this has something to do with teaching hospitals seeing more complex patients, subsidizing low income patients, and training residents like me).

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On cabdrivers and patient empowerment

Posted by Ishani Ganguli May 2, 2013 07:00 AM
The cabdriver pulled up to take me to the community hospital where I work several weeks each year. Settling into the back seat, I made my request before he reached the intersection: "Could you please take 93 South?" He was quick to ask me why, and I hesitated. I had taken this route dozens of times and had usually found it to be faster than the alternative, I said, but what if there was something he understood, with his superior highway smarts and his advanced navigation technology, that eclipsed my knowledge? He nodded at my explanation and took the right onto the highway. 

A few minutes into our ride, I picked up my cell phone and my mother opened with her usual dramatic flourish. This time: "Ishani, you’re never going to fix your health care cost crisis." Earlier that day, she had gone to her annual physical with her primary care physician (PCP) of more than a decade. As in the previous year’s visit, her doctor ordered an electrocardiogram (EKG, or heart tracing) even though my mother has no history of heart disease. She gave my mother a lab slip to check her blood counts and electrolytes - tests that have limited value when performed routinely and not for a specific medical issue. She referred my mother to a gynecologist for a pap smear even though she is older than 65 (the guideline-recommended age to stop this screening for cervical cancer).

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A week after the Boston bombings, a chance to reflect

Posted by Ishani Ganguli April 22, 2013 02:50 PM

I was sitting in the resident workroom at Massachusetts General Hospital (MGH) when my co-resident showed me the text from her sister: two explosions had shaken the finish line of the Boston marathon. Though news sites had not yet published the headline, it was immediately corroborated by the cacophonic wails of ambulances heading towards us and our shock was quickly replaced by the urge to learn more and to do something. We scrolled through the emergency department’s internal log and saw with horror as patient after patient entered with the chief complaint of "amputation." We made our way to the residency office to report our availability to pitch in, passing orthopedic residents called in to help and sharing the elevator with a case manager frantically wheeling one of several patients to another part of the hospital to make space in the Emergency Department (ED) for the expected deluge of injured runners and onlookers.

A few of us were recruited to help clear out the ED by expediting hospital admissions for patients with medical problems like pneumonia or heart failure. Other internal medicine residents continued their usual - now busier - work on the floors. Those, like me, on elective stayed close by in the off chance we were needed. We huddled in the resident lounge, checking in with our families and friends, scanning the ED log, and reading out loud Twitter updates filtered by source credibility. We bemoaned our internal medicine training - we could treat a heart attack but were useless when it came to mangled limbs - and shared our magnified respect for our colleagues in surgery and emergency medicine.

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Chronic care at Walgreens? Why (not)?

Posted by Ishani Ganguli April 10, 2013 11:00 AM

Walgreens, the country’s largest drugstore chain, announced on Thursday that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.

A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes' Bruce Japsen (though it's not clear how the retailer would share the financial risk or savings in such a model). 

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Revisiting non-urgent emergency department visits

Posted by Ishani Ganguli March 29, 2013 12:15 PM
Yesterday, I cared for one patient with chest pain, another with burning pain on urination, and a third with sharp belly pain. Two of the three came to see me in my primary care clinic, the third in the intensive care unit (via the emergency department (ED)). Who went where? You'd be surprised.

In her most recent post, Pauline Chen writes about the unfairness of penalizing patients for visiting the ED for non-urgent problems - after all, it is often difficult for doctors, let alone patients, to define them as such until after they have passed. She cites a recent study of nearly 35,000 ED visits finding that the symptoms that brought patients in for what were ultimately primary care-treatable conditions were indistinguishable from the symptoms that brought in the sicker patients.

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Tethered to a pole: the challenge of end of life decisions

Posted by Ishani Ganguli March 22, 2013 11:59 AM
When I attended the Association of Health Care Journalists (AHCJ) conference in Boston last weekend, discussion swirled on the topics of unsustainable costs of care, doctors’ incentives under traditional payment models to order more tests and treatments, and the struggles of patients’ family members to avoid unwanted care at the end of life. That Sunday night, I was back at my day job (so to speak) in the Cardiac Intensive Care Unit (CCU), a place synonymous with the utmost care and where I first grew accustomed to difficult conversations about such topics. 

I was chatting with some of the nurses during a lull in our work and the conversation turned to a patient several of us had cared for in the past. He was an 80-something, emaciated man with an irreversible lung condition who seemed on the verge of passing on for much of his hospital course. The medical team had spent hours talking to him and his family about how aggressive to be with his care. Consistently, he and his family that he should have it all - even when that meant a tracheostomy tube through a surgical hole in his neck to help him breathe, accompanied (necessarily) by a feeding tube that would directly enter his stomach. One morning a few days after the procedures, the patient awoke and began cursing in a loud whisper at anyone within earshot - why was this object in his throat, and this other one in his belly? Who would do this to him?

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US patients can choose better

Posted by Ishani Ganguli March 11, 2013 09:30 AM

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You get a terrible headache. What do you do next? Take ibuprofen and try to sleep it off? Call your primary care physician (PCP) for an appointment? Dial 911 for an ambulance to take you to the Emergency Department (ED)? What if that headache comes with a cough and shaking chills? 

Would an ad influence your decision? 

I came across this image on Facebook - part of a British campaign launched in late 2011 by the Leicester region of the National Health Service (NHS) in response to winter pressures on their Accident and Emergency units (A&Es, aka EDs). The campaign website lists the uses for various care options (Self-Care, Pharmacy, General Practitioner (aka PCP), Urgent Care Centre, Emergency Department & 999 (translation: 911)) and lets you download an iPhone or Android app to make the choice.

As it turns out, similar campaigns were launched in other regions of the United Kingdom, spurred by a national policy mandate to reduce A&E traffic and and to treat patients in the appropriate medical settings - after all, mismatches cost patients time and money in addition to placing a larger financial burden on the health care system. One such effort in London even involved planting an NHS employee in front of the A&E to redirect patients with minor issues to the on-site primary care clinic.

The ad struck me (and perhaps the 12,500 others who shared it on Facebook) for its uniquely British bluntness and the impression that, even beyond that bluntness, it would be hard to imagine it in the US.

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The bitter pill, chewable for doctors

Posted by Ishani Ganguli February 28, 2013 11:15 AM
When I read Steven Brill’s epic takedown of health care costs in Time, my first reactions were sticker shock and outrage at the capricious ChargeMaster that has pushed so many Americans into bankruptcy. This was followed by unease: Did I really need to use that second square of gauze (priced at $77 a box, according to Brill) after placing that central venous catheter the other week? 

As he dissects a series of medical bills and follows each line item to its source, Brill points the finger both at marked-up prices by manufacturers and hospital administrators stemming from our lack of price controls and at the quantity of line items (ie. the overuse of resources). Setting aside the critical need for payment reform and true price competition, doctors have a significant role to play in mitigating that second offense. To this end, we’re now meant to learn about medical costs as part of our medical training, though institutional norms and perverse incentives have made this challenging.

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About the author

Ishani Ganguli, MD, is a journalist and a third-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She studied biochemistry and Spanish at Harvard College and received her More »

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