Chris Moriates, MD, assistant dean for healthcare value and associate professor of medicine at the University of Texas at Austin Dell Medical School, drew insight from writer David Foster Wallace on Tuesday afternoon as he discussed overuse in hospital care.
He cited a story by Wallace: Two young fish are swimming along when they pass an old, wise fish who says, “Mornin’, boys. How’s the water?” One of the young fish asks the other, “What the hell is water?”
For hospitalists, the culture is their water: Even though they’re swimming in it every day, it can be an abstraction that gets little attention. But the culture is what needs to be tended to in order to turn the tide of unnecessary expenses, Dr. Moriates said in his talk, “Overcoming a Culture Overrun with Overuse.”
“How we’re addressing this problem is by making guidelines, algorithms, evidence-based medicine, Choosing Wisely lists,” he said during the well-attended session in the High-Value Care track. “It’s important that we codify our practices in these ways. But it is insufficient, because we must recognize that we are all swimming in that same water.
“If we don’t change this culture, this water, we will not make any progress.”
A 2013 survey by the Society of Academic Emergency Medicine found that 97% of physicians thought that at least some of the imaging they have personally ordered is medically unnecessary. And a 2011 Annals of Internal Medicine study found that organizational culture was a key factor in distinguishing hospitals with high and low 30-day mortality rates for patients with acute myocardial infarction.
He pointed to lessons from his previous institution, the University of California San Francisco, where they launched Caring Wisely, a program meant to support front-line clinicians who want to eradicate unnecessary costs. Part of the program involves funding clinicians up to $50,000 for their projects. One such project found that feedback to surgeons about expenses, and a small financial incentive to the department to keep costs down, was associated with reduced operating room costs.
This kind of change can be done anywhere, he said. After all, culture change, he said, can start with something as small as encouraging patient interaction by asking, “What questions do you have?” rather than “Do you have any questions?”
“I don’t want you to leave and think, ‘Well, unless I work somewhere like UCSF, where they’re going to give me $50,000 to do this, or I have an amazing boss like [Dr.] Bob Wachter [the former SHM president from UCSF who coined the term “hospitalist”], there is nothing I can do about this,” Dr. Moriates said. “It turns out that, yes, that is important for changing culture, but each of us has a personal responsibility.”