In the academic world, ‘tis the season of interviews. The medical school’s admission committee is sorting through hundreds of applications, each one telling a story about one person’s journey. Fourth-year medical students are interviewing residency programs. They are looking for a match for the next 3 or more years. Then there are the job interviews to replace faculty who transfer or retire.
Part of the application/interview process is assessing knowledge and technical skills. There are test scores, such as MCAT (Medical College Admission Test) or Part One of the boards. Those are important, but not decisive data. There are letters of reference to review. Garrison Keillor notes that, in his fictional town of Lake Wobegon, all the children are above average. Based on letters of reference, nobody graduates in the bottom half of the class of medical school either.
The real purpose of the applications and interviewing is to go beyond knowledge and technical skills. There is an assessment of the person and his/her potential to be a fine physician. There are various interpretations of what that means. I think a big piece of it is empathy, defined as the ability to connect with the patient on an emotional level and truly understand what the patient is feeling and suffering. This summer and fall, there has been a flurry of books and articles noting how students enter medical school altruistic and compassionate but get most of that drummed out of them during medical school.
I don’t really understand the hubbub. This phenomenon was well known a generation ago. The sleep deprivation of residency used to be effective at eliminating any recalcitrant empathy. With the new duty hours, the sleep deprivation mechanism has been attenuated. There are no data yet on whether shorter duty hours produce more empathetic doctors. No data yet to indicate that they are making fewer mistakes, either.
There also has been a recent flurry of activity attempting to increase rational thinking in medical care. Not rationing, just being rational. Three years ago it was Provenge, which cost of $93,000 to add 4 months to the life of an elderly patient with metastatic prostate cancer. Medicare decided to cover the cost. Last year, the poster child was Zaltrap, with an estimate of $75,000 to add 42 days of life to someone with metastatic colon cancer. It was very expensive and marginally better than cheaper, older drugs. In an Oct. 14, 2012, op-ed in the New York Times, three physicians from Memorial Sloan-Kettering Cancer Center indicated that the hospital would not use the drug because of its poor value.
Now, this issue has simultaneously become the cover story for both New York magazine ("The Cost of Living," Oct. 20, 2013) and MIT Technology Review ("A Tale of Two Drugs," Oct. 22, 2013). Those are two extremely disparate magazines with very different target audiences, each addressing the same issue. Surely, that is a reason to sit up and take notice. There is a tipping point at which the cost of a medical therapy becomes irrational. The empathetic doctor of the future cannot hide behind a claim that life is priceless. A more nuanced understanding of the financial limits of care will be necessary.
Medications aren’t the only expensive medical care. Diagnostic tests also can be of poor value. Over the past 2 years, many states and hospital systems have introduced pulse oximetry screening of newborns before discharge to detect rare, asymptomatic critical congenital heart defects. Analysis put the cost at about $40,000 for each incremental case identified prior to discharge.
There are no data yet to indicate how many of those early detections translate into a life saved, and it is beyond the scope of this editorial to make such an evaluation. I would hope, however, that those promoting this policy change are nuanced in their thinking rather than being swayed by a photo opportunity for the governor to hold a baby identified by the program in New Jersey. Alas, that was not my impression at a recent American Academy of Pediatrics event. That doesn’t mean I’m against this practice. I’m just concerned about the quality and process of the policy making. New York magazine and MIT Technology Review have different approaches to the problem. Truth probably lies somewhere in between.
Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. E-mail him at pdnews@frontlinemedcom.com.