Thursday, January 19, 2017

Applying Behavioral Economics to Patient Care

Psychologist Daniel Kahneman, along with his frequent collaborator Amos Tversky, are the fathers of the field of behavioral economics. Kahneman was awarded Nobel Memorial Prize in Economic Sciences in 2002 for his work (Tversky was deceased, and thus not eligible). To bring his work to a broader audience, he published "Thinking, Fast and Slow" in 2011:

The basic premise of the book is that our brains actually function via two systems, which he terms System 1 and System 2. System 1 is instinctive, utilizing heuristics to make decisions quickly. A heuristic is a 'rule of thumb', a device to boil down complex information to a simple choice. In other words, it acts as an approximation, that is usually 'good enough' for the situation at hand. System 2 is calculating and rational; it functions more like a computer, coolly processing inputs and trying to generate the optimal decision as an output.

Kahneman's work points out the biases inherent to both of these systems. His most famous result may be prospect theory, which basically shows that humans do not value incremental changes in probability equally, and that they are susceptible to whether those changes are framed as gains or losses. Another big point that Kahneman makes is that our "selves" really consist of two separate entities: our experiencing selves, and our remembered selves. For example, think about a strenous hike or other physical activity you did. In the moment, your experiencing self may be in agony from the stress and pain; however, your remembering self may view it as a very cherished memory because of the overall payoff.

What does this have to do with medicine? Everything! Both patients and doctors suffer from these biases. While the biases are part of being human, that does not mean we should simply accept making poorer decisions because of them. As a physician, here are some things you can do to mitigate these biases from how you decide.

Gathering A History

When you first meet a patient, you will necessarily have to make an initial assessment. That 'subjective' portion, the S in SOAP note, is the lynch pin for the rest of your encounter. If you have bad information, you will order the wrong exams, make the wrong diagnosis, and implement the wrong plan.

Garbage in, garbage out.

Therefore, getting a precise history is critical. However, to do this, you must combat both your own biases and the patient's. The big one to combat here is recall bias. For example, patients with a history of cancer who present with abdominal are more likely to over-emphasize or recall factors that may suggest a mass as the underlying cause of their pain. Do not disregard this history, but do try to correlate it with objective data, such as a CBC to check for anemia, or imaging.

Ordering Tests

The explosion in objective data one can acquire on a patient has been a major boon to healthcare. However, there is a downside to such tests. This bias is on the provider's side. Whether it is an anchoring/recall bias (the last patient with shortness of breath had a pulmonary embolism, so now every future patient with SOB has a PE) or satisfaction of search (one abnormal test result precluding ordering other relevant tests), these biases can lead to either the under- or over-utilization of appropriate testing modalities.

One way to guard against this is to understand treatment algorithms at great length. While there is a tendency to avoid 'algorithmic thinking' in medicine, the notion is often misapplied. One can go beyond algorithms only after they have fully mastered them, and can confidently assess that the current patient does not fit the algorithm. This is a wholly different matter from simply ignoring an algorithm altogether.

Making a Plan

Finally, once all the history and data have been gathered, and an assessment, it is time to come up with a treatment plan. As Kahneman's book title implies, this is a good time to think slowly. Have all the patient's problems been addressed? Does every abnormal lab value have either an explanation or a plan to address it? A good treatment plan will also include some way to assess its own effectiveness, whether that is by scheduling a follow up exam or test, or some other objective measure. A plan without follow up is simply wishful thinking.

Ultimately, the practice of medicine is a human practice, subject to human biases. However, as our understanding of these biases advances, it behooves us to mitigate these biases to the best of our abilities. If we are to do no harm, we must ensure that we unblind ourselves to the harm our biases may cause.

Sunday, January 15, 2017

The New and Improved Amazon Rewards Card

Regular readers of this site likely realize that we're big fans of Amazon. In addition to using e-books and being a Prime Student member, another way to maximize your Amazon benefits is by having an Amazon Rewards credit card.

Previously, the card paid 3% back for all purchases made on Amazon and 1% everywhere else. The new card now pays 5% back on all Amazon purchases for Prime members, 2% at restaurants, gas stations, and drug stores, and 1% everywhere else. It remains free, with no annual fee.

The card becomes another payment option in your Amazon account. After the monthly balance is paid off, the reward points automatically show up on the Amazon checkout page. Simple!

For a limited time, Amazon is offering a $70 instant bonus upon approval. If you are looking for a new stethoscope or maybe even a new tablet device, that would go a long way towards it! Following on the last post though, if you already carry credit card debt, make sure to pay off all your balances first before pursuing new lines of credit and make sure to pay off your balance *every* month.

This post contains affiliate links, which means the blog receives a commission if you make a purchase using those links. For more info, please read the full disclaimer.

Thursday, January 12, 2017

Financial Advice for the Future Physician

Dr. Jim Dahle runs the popular healthcare-professional blog White Coat Investor. One of his posts detailed 8 Financial Tips for students looking into a medical career:
Choose the cheapest school you can get into

The decision of which school to attend will have a greater impact on your finances for the next 5-20 years than any other decision other than who/if you marry and what specialty you choose to practice. Choose wisely. I’ll give you a hint–Most medical schools in this country provide a pretty comparable education. Most of what you learn in medical school will come from what you teach yourself and the pearls dispensed to you freely by interns, residents, and other doctors you come into contact with. Little of that learning is dependent on the school you choose. Thus, choose the cheap state school if you can get into it. Don’t forget that costs aren’t limited just to tuition and fees, but also to the local cost-of-living. That school in Boston, New York, or San Francisco is going to cost you a lot more than the one in Omaha or Albuquerque.

Consider the merits of “scholarship” programs carefully

There are several organizations that would like to pay for your medical school in exchange for a commitment. The military Health Professions Scholarship Program is the best known, but the US Public Health Service, Indian Health Services, and other private deals also exist. None of these programs is a “scholarship” in the traditional sense of the word, and many a “scholarship winner” has later realized he would have been much better off, personally and financially, if he hadn’t been awarded the “scholarship.” As a general rule, use these programs only if your career goal is to be a military doctor or a rural primary care doctor. Choosing them for the money is almost surely a mistake you will regret.

Personally, I can attest strongly to his first piece of advice. Choosing a cost-effective medical school has meant the difference between graduating essentially debt-free versus graduating with loan repayments stretching out as far as the eye can see. As life progresses, your costs will increase, so that "manageable" monthly repayment will become increasingly burdensome, especially if you are interested in purchasing a house or having a children as you near the end of the long road of medical training (or already have those obligations!)

For the rest of his tips, check out Dr. Dahle's post 8 Financial Tips for Pre-meds and Medical Students.


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