GlassHospital

Demystifying Medicine One Week at a Time

Bloodletting, Vol. 1

I’ve just finished a month “on-service” as a teaching attending for a general medicine team here at GlassHospital. This means I served as the physician of record for every patient admitted to the team.

You might find it interesting to know that patients admitted to the hospital’s general medicine service get assigned to their teams by random assortment. Since there are five teams, one team takes call every fifth day. In true “general” fashion, this allows for assortative distribution of diagnoses, so that the doctors-in-training experience as much as possible over the course of their three year residencies.

I’m now a decade out of my residency, and reflecting on the distance, I find that the biggest constant in hospitals over that time is change.

In the past ten years, there are dozens of new drugs we use routinely. Information technology has moved front and center in all of our operations. Our patients continue to experience big procedures in less invasive ways, be they laparoscopic (the use of telescopes and tiny incisions versus ‘open,’ wide-incision surgeries), endoscopic (using fiber optic tubes to see, biopsy, and treat all parts of the digestive tract), or intravascular (procedures and devices done in the blood vessels with nary an incision).

There certainly is more attention paid to money in health care; when I trained we focused almost exclusively on what we thought best for patients. Now it seems as though everything is filtered through a lens of financial impact. I don’t think imparting a sense of financial ramifications to our trainees in necessarily a bad thing, but it does alter the fundamentals a little.

One thing hasn’t changed over the decade, though: Our incredible reliance on daily blood draws from our pin-cushioned hospitalized patients.

Every morning at 6am, nearly every patient that’s been admitted to our team gets a visit from one of the friendly phlebotomists–people from our central lab who poke at the crook of their elbow (medical speak: “antecubital fossa”) or somewhere else on their bruised arm or hand with a needle and take one, two, or more tubes of blood to run “daily labs” on.

Some of these poor patients are phlebotomized multiple times per day. This can be medically necessary, if, say, a patient is internally bleeding and we need to make sure that their blood count is not dropping. Another medically necessary example occurs when a patient’s kidneys or liver are damaged and we follow their lab numbers to know if our therapies are helping or hurting.

I submit, however, that most of the blood tests we order are superfluous, and ordered more out of a sense of tradition and availability than any actual medical necessity.

I’m as much to blame as the interns and residents that order these blood tests. I’m part of the culture, though I’d like to think better of myself.

When I was an intern, I learned quickly to order a CBC (“Complete Blood Count”) and BMP (“Basic Metabolic Panel,” formerly known as a “Chem-7” or “SMA-7”) on nearly every patient every day they were in the hospital, lest the attending chew me out for not having the data ready by the time we were on morning rounds together. It only takes one embarrassment like that to change behavior. Fear of failure induces interns to systematically order labs on all their patients so they don’t pick and choose and thereby omit the wrong case.

It’s a game of laboratory roulette every morning–one in which no intern wants to get caught without chips on all the numbers if at all possible.

Beside the unfortunate human cost of all this blood drawing, what does a financial analysis reveal?

Turns out the cost (and revenue!) of having a patient in the hospital dwarfs the cost of obtaining and running the lab tests on the margin. So, for any one patient, scrutinizing lab draws doesn’t feel like much of a cost-saving measure. But, in the aggregate, it could actually make a world of difference.

Changing culture is hard. As a teaching attending only a small fraction of what I teach to my residents will stick. So I feel it important to choose my battles wisely. Preaching about the human and financial costs of superfluous lab testing has a nagging feel to it. I know that people tune out nagging, especially when it runs counter to their prevailing habits and survival instincts.

Stay tuned to GlassHospital to find out if I can summon any administrative will to change this culture, saving both patient agony and medical money.

4 Comments

  1. I agree that it’s pressure to never be missing a lab the attending asks for that leads to this phenomena. Slight pressure the other way can help. Nicely have them justify the labs they do order (would you do anything different if the labs positive or negative?), be generous when they don’t have a lab you want and defend your team when the nurses yell at the resident because they’re ordering a lab after rounds instead of the night before for morning phlebotomy.

  2. elizabeth rosenbaum

    April 4, 2010 at 10:16 am

    “There certainly is more attention paid to money in health care; when I trained we focused almost exclusively on what we thought best for patients. Now it seems as though everything is filtered through a lens of financial impact. I don’t think imparting a sense of financial ramifications to our trainees in necessarily a bad thing, but it does alter the fundamentals a little.”

    Don’t lose sight of this either. I get that the cost of health care is important, but I think that the more attention the doctor can pay to the patient, the more we could save! Knowledge is power!!

  3. $$downthedrain

    May 20, 2010 at 8:36 am

    We in the lab, call it a “fishing trip”. This is when they order every test under the sun hoping something will come out positive. Of course, then one or two non specific tests are slightly abnornal and then more tests get ordered to further confuse the picture.
    The unfortunate thing is that a vast number of patients will never come back to our institution for follow up. So, when expensive tests are ordered and the results come back after discharge, no one even looks at them.
    This is the draw back to treatment at large academic medical institutions where more is always better and where “I read this in a article” so we should order it is one reason for ordering tests.

    • glasshospital

      May 20, 2010 at 6:41 pm

      Thanks for your comment. I think, perhaps a bit more grandiose, we call them “fishing expeditions.” I’d really like to do an analysis of all the labs ordered and come up with a rational plan–and see the financial impact. My colleagues would cry foul, I’m afraid.

      -GH

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