Teaching Future Physicians to Choose Wisely
On any given day a physician may hear, “Doctor, I really need antibiotics for my sinus cold.” Or, “Doctor, I’ve had this back pain for a week, and I’m thinking I need an MRI—I just want to know what this is.”
Pablo Joo, M.D.Patients requesting questionable interventions such as these are part of every physician’s experience, and Einstein medical students will be more prepared to field them thanks to an educational program based on the Choosing Wisely® initiative of the American Board of Internal Medicine (ABIM) Foundation.
A goal of the foundation is to encourage clinicians and patients to talk about their expectations for proper care based on evidence, safety and cost, with a focus on preventing the inappropriate use of tests and procedures. Over 70 medical specialties have generated lists of tests and procedures that should be questioned.
Grant support to develop a Choosing Wisely curriculum at Einstein came from a National Institutes of Health (NIH) R25 grant with further support from a new ABIM Foundation grant, explained Dr. Pablo Joo, assistant dean for medical education at Einstein and principal investigator of the grants. The curriculum calls for the development of observed structured clinical examinations (known as OSCEs and pronounced “OSS-keys”). Students practiced what they learned on “standardized patients”—actors trained to portray patients.
The OSCEs—on antibiotic stewardship and back pain—cover multiple facets of caregiving that included demonstrating empathy, obtaining and providing information, initiating conversation, and practicing good medicine and economics: “We’re teaching future doctors to provide care more wisely as a way to both improve health and reduce costs,” said Dr. Paul Marantz, associate dean for clinical research education and co-investigator on the NIH R25 grant.
“All too often, the physician takes the path of least resistance and writes the prescription or orders the test,” added Dr. Felise Milan, director of the Ruth L. Gottesman Clinical Skills Center, where the back pain OSCE took place. “This training showed our students that their responsibility is to educate their patients and negotiate to devise an appropriate plan based on wise choices.”
Antibiotic Stewardship
Felise Milan, M.D.The antibiotic OSCE was based on a viral rhinosinusitis online module developed by the American Academy of Family Physicians. It was presented to third-year students during the family medicine clerkship. Students practiced how to communicate effectively with patients requesting antibiotics for a cold infection.
“Health literacy in the United States is at the fourth-grade level, so you have to be able to explain health concepts to people in language they can understand.” said Dr. Joo, who also is associate professor of clinical family and social medicine at Einstein and an attending physician at Montefiore.
He explained, “It’s better to say to patients that most colds are caused by viruses. Antibiotics treat infections caused by bacteria only and not viruses. Treating a cold caused by a virus with an antibiotic now could make the antibiotic not work later when you need to treat a bacterial infection.
Scanning for Back Pain?
The basis for the back pain OSCE was an x-ray for back pain module developed by the American College of Physicians. Students preparing for their third-year clinical skills assessment learned to gently guide patients with back pain to try conservative treatments such as heat and acetaminophen before moving on to more costly, and possibly not helpful, imaging and other therapies.
“It’s questionable as to how much bang for the buck you get from ordering imaging studies too early for non-emergent, uncomplicated low back pain, needlessly irradiating the patient without any positive benefit or change in management,” said Dr. Joo.
“We know that sometimes testing leads to more testing, more anxiety and possibly even harm to the patient if the test is invasive and dangerous,” added Dr. Milan, who also is professor of clinical medicine at Einstein and an attending physician at Montefiore. It’s far better, in the words of the ABIM Foundation, to use medical resources wisely and avoid unnecessary care.
Partnering with Brown University
Einstein will split the $25,000 ABIM grant with Warren Alpert Medical School of Brown University, Dr. Marantz’ alma mater. “After the Choosing Wisely curriculum has been in place for a year at both schools, we’ll compare notes and make the most successful aspects of the initiative and its evaluation a permanent part of the curriculum,” said Dr. Joo.
“These OSCE modules represent a good start toward addressing an important aspect of providing high-quality care,” he added. “Perhaps in the future, grant funding will support OSCEs in other areas where wise choice discussions are needed, such as cough medicines for kids under age 4, performing pap smears in women under age 21, or imaging for uncomplicated headaches. The list of possible healthcare choices that our future caregivers and patients should be cognizant of is quite long.”
Posted on: Thursday, June 09, 2016