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Hiding Behind High Value Care: A Podcast with Vinny Arora and Chris Moriates



You're the attending physician on a teaching service.  Your resident says we shouldn't order a CT because CT's are over-used for this condition, and represent overuse, waste, and low-value care.  In this case, however, you suspect that's not the resident's real reason.  The real reason behind the resident's decision is that they are serial minimizers - residents who make little of potentially important findings.  You feel they might be hiding their minimizing behind the sexy, trendy notion of providing "high value care."

Does this sound familiar to you?  It did to me.  I've been in the awkward situation of being the consulting palliative care physician saying to the primary team, I know they have cancer and that's the most likely explanation for this abdominal pain.  I also worry that this pain is out of proportion and different from other pain I've seen, and I think it should be evaluated with further testing.  Kind of strange to say that as the palliative care doctor.

Kind of strange as well to hear that perspective exposed by Chris Moriates and Vinny Arora, who spend most of their academic careers fighting against wasteful low-value tests and treatments (they run a non-profit called Costs of Care).  To be sure, they note this problem is not as great as overuse of consultants, tests, and treatment.  The challenge, as Stephanie Rogers our guest host (and guest fiddle player!) points out, is coming up with the right words to teach "right sizing" care to the patient in front of us.  And what are the root causes of minimizing?  Blame the housestaff would be the easy way out, but Chris and Vinny don't take that road.  Read more about their thoughts in this article in the Journal of Hospital Medicine and listen to or read our podcast!

-Alex @AlexSmithMD


  


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Transcript

Eric: Welcome to the GeriPal Podcast! This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, we have a lot of people on this podcast with us today.

Alex: We've got a big podcast for you folks. We have in the room, we have Stephanie Rogers, who's in the Division of Geriatrics, geriatrician here at UCSF. Welcome - is this your first GeriPal Podcast?

Stephanie: This is my first one.

Alex: First, but not last, GeriPal Podcast. Then we have Matthew Growdon, who's visiting from Boston, who is a chief resident in internal medicine at the Brigham and Women's Hospital and did a geriatrics fellowship last year. Welcome to GeriPal Podcast.

Matthew: Thank you.

Eric: And we are not minimizing the amount of people on this podcast.

Alex: We also have two people on the Skype line.

Eric: Yes.

Alex: We have Chris Moriates, who's a hospitalist at Dell Med, and works with Vinny Arora, who's a professor at the University of Chicago, and also a hospitalist and a social media star. They both work at a nonprofit called Costs of Care. Welcome, Chris; welcome, Vinny.

Chris: Thank you.

Vinny: Thank you.

Eric: We're going to be talking about Vinny's and Chris's article called Tackling the Minimizers: Hiding Behind High-Value Care.

Alex: Ooh.

Eric: This should be a good controversial subject.

Alex: Yeah.

Eric: But before we do, hoping for a song request. I think the song request is going to go to Stephanie.

Stephanie: Okay. I am going to request one of my favorite fiddle songs, The Devil Went Down to Georgia.

Alex: And awesomely, you're going to play the fiddle part, which is clearly going to be the best part about this song. It's amazing.

Stephanie: We'll see about that.

Eric: We had opera on last week, and we're doing fiddle this week.

Alex: We're stretching in new directions, Eric. We're going in new directions.

Eric: I want to see you do a hip-hop, or like a rap.

Alex: Uh, yeah, that hasn't happened yet. There was that time somebody requested Alicia Keys, and I played one stanza.

Eric: All right.

Alex: All right. Here we go. One-two-three-four.

Alex: (singing).

Eric: That was perfect in every way.

Alex: See, I told you the best part was going to be the fiddle.

Vinny: It's awesome.

Stephanie: Well, I think he's really great.

Eric: Perfect fiddle playing there.

Alex: Amazing.

Eric: That was pretty awesome. Are you going to do the full song at the end? Is that the plan?

Alex: No, no, no, no.

Stephanie: Oh, no. Someday, though, we're going to practice and we're going to really get the band together.

Eric: The band? Do you have a name of the band?

Stephanie: Not yet.

Eric: The Minimizers!

Alex: There you go.

Vinny: Well, Chris, you can do punk rock. That could be your next piece.

Stephanie: Ooh, I like that.

Eric: Chris, could you play the band?

Chris: No, but when I moved to Austin, Texas, it was the first time I didn't live in an apartment or dorm environment since college. So the first thing I did was buy a Marshall amplifier for my guitar.

Alex: Oh, nice.

Chris: And fulfilled all my 16-year-old dreams.

Alex: Yes.

Chris: But I wasn't punk yet in high school and college.

Eric: Well, I feel like you live in Austin, you have to be in a band, now, right?

Chris: Yeah. Yeah. Totally. I'm working on it.

Stephanie: Yeah, you got to play at South by Southwest. That's when you know you made it.

Chris: That's right.

Eric: We are going to be talking about your article published in Journal of Hospital Medicine in May of 2019, called Tackling the Minimizers: Hiding Behind High-Value Care.

Eric: Can you give us a two-sentence description of what a minimizer is before we go into this article?

Vinny: Yeah, sure. A minimizer is basically, we denote it as a trainee who is using high-value care as a backdrop and an excuse to not order a test, and to do less, when in fact that test is indicated.

Eric: Whoof! Before we talk more about that, how did you get interested in this subject? What organization did you say you're a part of?

Vinny: Costs of Care.

Eric: Costs of Care.

Eric: Is that an organization devoted to increasing the cost to care?

Stephanie: We do that well in this country.

Eric: We do. How else can we increase cost to care?

Vinny: Yeah.

Eric: That sounds like the opposite of a lot of what you focused on in the past. How did you get interested in the idea of minimizers as a subject?

Vinny: Well, like most things, I think when you're on service as a hospitalist, you get ideas. I think Chris and I both view ourselves on the front end of the high-value care movement, as hospitalists and teachers and really highlighting the importance of things like choosing wisely and making sure that our trainees are not excessively ordering tests or dealing with overuse.

Vinny: But one of the things I had noticed was that sometimes I would encounter a resident; usually a burned-out resident, somebody who was trying to cut corners, who was like, "You know, I think the patient can go home, and we don't need to order a chest x-ray." And I'm like, "But they might have pneumonia, and that's important to know."

Vinny: And they're like, "Well, you know, we're trying to practice high-value care." And I'm like, "That's not exactly how high-value care works."

Vinny: I had just thought it was happening to me. But then in conversations with Chris, we were both like, "Hmm, this is something. And something is out there, and we need to be on the forefront of calling it out so that this is not misappropriated as something that's part of the high-value care movement."

Chris: Yeah, I think for those who may not know, Vinny and I spent the last, at least eight years of our careers really trying to push the high-value care movement; the idea of overuse causes harm physically and financially. We need to cut out waste and not do too much.

Chris: And I actually remember, I think I was either a first-year faculty member, maybe when I was a resident, and I was giving one of my first talks on this at UCSF.

Chris: One of the residents raised her hand and said, "Aren't you worried that the pendulum's going to swing back the other way? And if we start doing this, we're going to do too little?" And I totally stopped.

Chris: I was like, "What, are you kidding? You know how far we have to go to do that?" And I think a couple things have happened. One is I left San Francisco and joined the real world.

Alex: What?

Chris: Which is interesting.

Eric: Wait, wait, wait, wait, wait, wait.

Alex: We don't live in a bubble! Are you kidding me?

Eric: You moved to San Francisco to Austin. Let's be fair-

Stephanie: It's like the same place.

Eric: It is, exactly.

Stephanie: Just hotter.

Eric: It is the San Francisco of Texas.

Alex: That's right.

Eric: Better music.

Chris: It's becoming the same place. My wife and I were realizing last night, when we couldn't get a reservation at any restaurant, we were like-

Chris: ... "What happened in the last three years?"

Stephanie: There you go.

Chris: But, honestly, when I started to realize that there is a lot of underuse that happens as well. And then, as Vinny and I reflected, we said, "You know, when you think about it, they're rare. But there have been minimizers all along in residency training, right?"

Chris: The joke is always that as a intern, you're scared of everything, you want to order everything. As you go through your residency training, you start to look for the most benign explanation; or perhaps the most cynical explanation for any given symptom and sign.

Chris: What we worried was, particularly with us, they would see us and they would think that, "Oh, well, now I've got a socially acceptable banner to put that behavior under." Right?

Chris: Instead of calling it cynical, instead of calling it, "I'm trying to shrug this off," now I can be like, "Well, I'm just trying to practice high-value care." Vinny and I are like, "That's dangerous." And we've seen it. Maybe it's because that's how they present it to us. So we thought we'd put it out there.

Stephanie: Yeah, and you talk about this a little bit in your article. But I think you were trying to discuss a few reasons of why you think people do that. I think some of the reasons you stated were burnout, and just general, this idea of shifting care to other providers sometimes; like, "That's an outpatient issue."

Stephanie: Which I think is reasonable, but I was wondering, when you see that, what do you do? What do you ask the resident?

Vinny: Well, I definitely would be always start with what's best for this patient, and really try to ground yourself in ... as an attending, you're really the role model, you're trying to really balance not only your trainees' needs, but really also reflect what it is that your patient needs, and model that for your trainees.

Vinny: I think that sometimes residency is hard; training is hard. In the middle of the night, you can get clouded, especially when you're dealing with all this pressures.

Vinny: And I think as an attending, you often have to be there to say, "Let's stop and really just think: what does this patient really need, and would they benefited by calling this consult? Or by watching them for one more day to make sure that X, Y, or Z was done?"

Vinny: Nine times out of 10, the resident at deep down, they know that that's the right thing. So they will be like, "Yeah, sure." It's almost like they were trying to float an idea, see if their idea floated past the attending, and move forward.

Vinny: But when you call it out, I think they start to realize that, "Okay, this is important. My attending is not falling asleep at the wheel. And I need to be much more careful about defending my decisions."

Vinny: I think it's actually part of teaching: letting people know that you need to be prepared to not only put your nickel down, but why you're putting your nickel down.

Stephanie: Yeah, I have to admit, when I first read the article, I had this moment in my head where I was like, "I'm a geriatrician; I consider myself; I don't know minimizer, but like a minimalist, right?" I started thinking about what that means, and how I make decisions on how I train people to make decisions.

Stephanie: That's why I was grateful for your article, because it really made me solidify what does that mean to be a geriatrician, or what I call a minimalist? Which is a little bit different than I think what is going on here. But what it got me thinking about is how we teach this idea.

Stephanie: I think sometimes in geriatrics, the patients that we see are very complex. They have a lot of issues going on. There's so many other factors that we have to weigh in when we're making a decision on whether or not to say, "Get an x-ray," when we thought the patient was going to go home, and when is it needed.

Stephanie: So I thought to myself about some of the complex things that we think about. Most importantly, being patient's goals. And you guys talk about this a little bit in your article.

Stephanie: When you talk about value, you talk about good clinical outcomes for good cost. But I think what gets missed a little bit is the patient's preferences for not only workup, but treatment and just the burden of healthcare that they have. Considering those things and talking about those things with patients.

Stephanie: I always think it's interesting to talk to residents, and ask this exact question: "Why don't you want to get the x-ray? What can we elicit from the patient to try to understand if this fits with what's going on."

Stephanie: For us, we have a lot of patients that just want to go home and don't want to be in the hospital anymore. So we try to help them meet their goals, but yeah, I just thought that was really interesting.

Stephanie: I was also just wondering if you have some specific stories of things that happened from residents; maybe any harms that have happened or anything like that.

Chris: Yes, Stephanie, if I can, I actually want to first jump in and just make the point that you made. Which I sort of wish now we made explicitly in our article, which is, "minimizer" is different than "minimalist." That's really important, right?

Chris: Because you can be a minimalist particularly in the correct setting, being a geriatrician, that is the correct setting. I think Vinny and I are certainly on board with that approach.

Chris: Minimizer, in a way, is a pathologic version, in that you are looking for the most benign explanation. Oftentimes, the motivation, if you get under it, is your own self motivation. For whatever reason your area is, we point it out.

Chris: Like, to make your work less. Or, even if it's not as ... malignant as that. It's simply is just, they're not purposefully doing it, but it's a harmful response. Whereas a minimalist response, maybe you're actually looking out for what's best for the patient.

Chris: I think that's what Vinny and I were saying was. But what we don't want is for the harmful motivation, the harmful response, of a minimizer to now be able to hide behind the flag that we have hoisted up, and said, "This is good care." Be looked for being a minimalist, and minimizers are now saying, "Look at me, I'm a minimalist." Does that make sense?

Chris: I, at least ... Interesting, Vinny, but make a distinction in mind of what is the underlying source of that behavior?

Vinny: Absolutely. I mean, I especially think that as geriatricians, you see the inpatient and outpatient spectrum across the continuum, and even people at home.

Vinny: Setting is part of this; that's why I think this really resonated with our world in hospital medicine. Because when you only have that narrow slice, it's very easy to be like, "Oh, that can be worked up as an outpatient."

Vinny: I see minimizing often as a patient will record a complaint, and perhaps because of anchoring or you're like, as you mentioned. Stephanie, there's only so many complaints you're dealing with -- this is like a patient with a lot of illnesses.

Vinny: You're focused on the top few problems that are acute in the hospital. The patient's now saying, oh, they have back pain, they have back pain, they have back pain. And maybe your resident's like, "Oh, they have back pain. It's chronic."

Vinny: So you can not only be a minimizer by just trying to overlook doing a test, but you could actually overlook a symptom by saying, "Okay, well this doesn't need to be worked up right now." I have examples where that, I mean, when you think about what we do stewards of hospital care, it's really to be as, provide the best value, high-quality care. But also be efficient.

Vinny: There's nothing more concerning than when four or five days into a hospitalization, that minimized problem, which we didn't look into; like that back pain, becomes the patient's top problem, and on the rounds you're like, "Let's step back here. The patient's not going to go home because we haven't addressed their main problem."

Vinny: And then lo and behold, they end up having a major issue with their back that needs to be worked up and may need a pain injection or something like that.

Vinny: I give you that as an example of a lot of times, there are some real biases at play. Some of them are cognitive biases, where you're anchoring on the top problem.

Vinny: The other biases are some implicit biases, even, where you're tending to ignore somebody's problem because you're like, "Well, this can be settled later. It doesn't need to be my problem right now. I'm just going to wrap up problem 1, 2, and 3, and then we're going to send them home."

Vinny: I think that's where you get into that dangerous zone of minimizing. That's not to say every problem ... The extreme is, I've seen residents who work up every single problem in the hospital. And you're like, "Okay, this really can be solved. This is better left for a primary care physician to discuss." So there's that middle ground.

Vinny: But with the high-value care movement, I think as Chris mentioned, it's created this defense for people to hide behind. I've seen it enough times that it was irking me, and it was really bothering me.

Vinny: And I was like, "We really need to call this out, Chris, so that people who are seeing this are aware that we have seen it too, and this is not what we mean by high-value care."

Chris: You asked for a specific example. We had a patient here who died, who was presented at M&M from a bowel perf. They didn't get a CT scan and the abdominal pain was completely minimized. "Oh, this patient uses opioids. Oh, this patient ..." And a ton of stuff.

Chris: Once again, the risk is that that lack of getting that CT scan can be sort of, as opposed to recognizing that there were biases at play, and this was a missed diagnosis, and so on and so forth, it can instead be like, "Well, we didn't want to overuse scanning. We didn't want to do this."

Chris: That was the thing. We want to make sure that people are really putting this in the right balance. Vinny and I wanted to make sure that we were putting a stop or, balancing that scale. Because we had pushed so hard, I think, to perfectly on the other end of that scale. Yeah.

Matthew: I guess as I think about this one thing that's coming to mind is I'm wondering if minimizers exist. You're kind of alluding to this; in what way different in different context, different populations are the subject of the minimization?

Matthew: Are there certain racial groups or socioeconomic strata or whatever, however you slice and dice things that are the subject of different trainees minimizing in different contexts? I'm curious if you guys could expand on that.

Matthew: As to your point of using high-value care as a shield, that in fact it may just be other inherent biases that we're using that as a justification not to follow up on the pain of someone who's often using opioids because we don't really want to know where that's going, for some inherent bias that we have.

Vinny: That's a great point. And actually, I will tell you sometimes when you talk about your article or your idea, like we're doing here, your wheels spin. So I will say, I have become a lot more interested in implicit bias, and have been reading a lot more about this topic.

Vinny: I do think that what you're saying is very salient. That it's more easy to minimize pain coming from an African American woman, for example. And maybe the issue of the minimizer is that we are concerned that 1), that shouldn't happen; that's number one. And 2), that hiding behind the high-value care movement as your socially acceptable banner or your defense, is not appropriate.

Vinny: And, furthermore, would undermine the high-value care movement. I remember Chris telling me an interesting ... Chris, I think you had sent something like, "We're always one case away from somebody unraveling high-value care, because they're going to say, 'Well, I didn't order that, and I missed this X, Y, or Z.'"

Vinny: You always have that in your head to be like, "Of course you know that you're standing behind appropriate care." But it's so easy in our environment to be charged and to be like, "Oh, well, why didn't your order this CT? We missed this diagnosis."

Vinny: Unpacking that the word "value" does not mean "do less" every single time. I think that's the hard part is when you ... It's like almost when people learn something. When they don't know a lot about the topic, and they learn just a little bit, they learn enough to be dangerous.

Vinny: This is why I think this is a particular issue with residents, because people can be really jazzed up about high-value care, then also doing less, and even the "less is more" nomenclature that's been promulgated.

Vinny: Really, the term "value" is not doing less; it's doing the right thing. That's one of the things I think we really want to spread as a take-home message.

Eric: When you think about value, how do you define it? Are you using the quality over cost? Or how do you think about value? Is that a better term that we just stick with, than minimizers and maximizers, because of the issues with both ... Now we have warring fractions of people in the hospital. "Oh, you're just a minimizer." "You're just a maximizer."

Chris: Yeah, no, I don't think we're advocating for labeling people, associating like that in a hospital. Value is what we're going to get. We define it generally, outcomes that matter to patients over total costs of care.

Chris: With Costs of Care, the way we've conceptualized in a way it is ensuring that we're providing care that is safe, that is affordable, and that provides a good experience. That is what people really want.

Chris: The idea is that's the goal that we're leading towards. I think as we've talked about, one of the risks are, is if you don't apply this in a thoughtful way, as has been pointed out, it can actually worsen disparities. If we're not thinking about that, and thinking about our biases as was discussed. I think that's important to us.

Chris: No, actually put it behind value ... I wanted to mention, Vinny mentioned that comment I made, about we're one case away. That actually was a conversation I had with Gurpreet Dhaliwal there in San Francisco VA, when I was a first-year attending.

Chris: I said, "I feel as though if we get a CT, and it caused harm or something, and people presented it, everybody would go like, 'Oh, well, yeah, that just happens.'

Chris: "But the moment I don't get a CT and it causes harm, everybody's going to say, 'Oh, it's because that guy is all about choosing wisely and high-value care.'" And all of a sudden, everybody's going to backlash against it. I was always very worried about that.

Chris: And now, seven years later, something, I feel like I'm starting to say, "Well, wait a second, we have enough momentum behind this. One case is I don't think is going to unravel this movement anymore." And now I'm a little worried that we're starting to see the opposite effect.

Alex: Hm. It's interesting. We got the pendulum swinging.

Chris: Yep.

Alex: But this is an important question here. What is the bigger problem: On a population basis, particularly we're talking about trainees, what do you see on a daily basis is the bigger problem: people who are ordering unnecessary tests, treatments, consultant requests.

Alex: Or, is the bigger problem low value? That's rather unnecessary. Let's say low value test treatment and consultant requests. Or, is the bigger problem minimizers, and people who are not ordering test treatments, consultant requests, that they should be in order to provide the best care for their patients?

Chris: We stated very clearly in our paper, 100%, it's overuse of the bigger problem.

Vinny: Absolutely.

Vinny: But I will say, that all care is, it's not random. There is a practice pattern based on the people you are working with. If you end up on service with a minimizer, somebody who has minimizing tendencies, you're going to go into overdrive, being like checking everything to be like, "Did we get everything we need?"

Vinny: That's a challenge, as a teaching attending, right? I mean, actually we referenced in our paper Jerome Groopman's work on patients as maximizers and minimizers of their symptoms.

Vinny: Although we don't want to label people, I do think that there are certain people that have tendencies towards minimizing. That's where in attending, you need to step in and give feedback and teach so that people understand that okay, they may need to step back and say, "All right, what's the best thing for the patient here?" And know this is not high-value care.

Vinny: I will say, at least the reason I felt very compelled to write the piece, is that in my inpatient block, when you said, "What's the problem?," yeah, most of my inpatient blocks, I'm talking about high-value care and waste.

Vinny: But the one time I'm not, and I'm not doing it for 14 days straight, because I'm paranoid about minimizing. I'm like, "Okay, this is a very different feeling. And this is something I wonder if other attendings had noticed. And clearly, they had.

Vinny: I mean, not only Chris, when the paper got published and we tweeted about it, there were tons of people who were like, "I've seen this happen."

Vinny: That was really interesting to me, to be like, "Okay, it's important that we have this discussion, so that we, as physicians, as teachers, are on the lookout for these practice patterns so that we can correct them."

Stephanie: I think you guys are on to something because I think we want to avoid these labels for trainees, "maximizer" or "minimizer," because one of the things that I learned in my amazing geriatrics fellowship-

Eric: Woo-hoo!

Stephanie: ... was this gray area that everything sits in. I think that's the true art of medicine, right? How do you sit in this gray area with every individual patient? I think that's what we really need to take time to teach our trainees.

Stephanie: I definitely, I'm a geriatrician that works in the hospital. And I would say, by far, I feel like I'm running around preventing harm all day long. Trying to get teams to think about why we're ordering something or trying to get teams to do simple things like remove the telemetry wires.

Stephanie: And they're like, "Well, why?"

Stephanie: "Just in case something happens." And I said, "Well, this person's all tangled up, and they're confused, and they're going to fall."

Stephanie: It's surprising to me how hard I have to work to sometimes help them think through some of these decisions that can actually have profound harm on patients.

Eric: That's why I think we should be cautious; I'm hearing that you guys are cautious with this language; because what I'm also hearing is the idea of minimizers and maximizers, focuses on things like tests and medications.

Eric: But when you're a maximizer, let's say, everybody gets a urine culture and every test possible. You're actually minimizing other things. Other things that are equally important. There's only so much time in your day. Only so many things that you can do.

Eric: And yet you're running around, you're minimizing some things, but you're also trying to maximize other things. So it's not purely like a, "Oh, a single construct that we're working with here." It's like trying to get people out of bed. You're maximizing that. Sounds like some other teams are minimizing it, but they're maximizing other things, while minimizing this concept of ambulation in the hospital.

Eric: Thoughts on that? Chris and Vinny?

Vinny: Yeah, I totally agree. I mean, I think there's only so much time in the day. That's why I bring up the symptom of pain, because I think there's obviously tests and treatments. But I think minimizing symptomatology is a very different experience.

Vinny: We don't need a label; we've all had a moment in our lifetime as a physician where we have potentially minimized somebody's pain, and thought, "Hmm." Later on, "Oh, that was real pain."

Vinny: So I think that the use of the term "minimizer" is not as important as minimizing behaviors, in the context of whatever you're doing. I think what I would say is, we want to be on the lookout for minimizing behaviors when it's not appropriate to minimize them. And, that people are hiding behind using the high-value movement as the defense for it, which is not appropriate at all.

Stephanie: On my end, I see so many ... I'm going to use the label "maximizer" so much, and in my head, I'm seeing so much harm happening. It's interesting to me that ... and I see what you're saying; it's just going to take one bad case where someone doesn't order a CT scan, and everybody's up in arms.

Stephanie: But what I wish, from my world, is that everybody was up in arms about the overuse of urine cultures and telemetry and all of these other things. That's what I get fired up about.

Stephanie: I think it's just interesting, though, that the things that we're seeing that look very different. Or maybe they're the same.

Chris: Yeah, here's the thing. We are 100% fired up about that, too. I guess we take for granted the fact that people already know that about us, and maybe they don't. But that's literally what we ... I mean, we have pushed Choosing Wisely education. We've created curricula around the physical and financial harms of overuse. I am 100% aligned with you about running around the hospital, taking off telemetry wires.

Vinny: Yeah.

Chris: We've led projects around that. At UCSF, Think Twice, Stick Once was a project that I helped lead with Dan Wheeler and a whole bunch of residents there, years ago about not sticking patients too often.

Chris: So, we're 100% aligned and it feels like perhaps language is getting in the way of what ... because I think what we're trying to say is the same. And yet we've got this concern around how things can be ... In fact, we share concern about how things can be labeled. Right?

Eric: Well, Chris, I think our biggest worry is you leave San Francisco, you go to Texas, and everything's bigger in Texas. We were just worried that you were changing on us.

Chris: Yeah, my residence here will attest, I promise when I see the nine-year-old too, I see, "Get that person out of the hospital." Right? Get them home. We are absolutely aligned with that.

Chris: But I will also mention, because we're on GeriPal, Vinny and I do see a different set of patients in general. We share a lot of patients, for sure, with y'all. But we see a different set of patients.

Chris: We're not just talking about geriatric patients, or palliative care patients, where the goals of care may be very different in some settings than what we're saying. Which is not to minimize overuse issue and all comers. But I just want to point out we are talking about a different population.

Stephanie: Yeah, but I would argue that we should think about all people in the same way. I think there's a kind of way we think in geriatrics. But I also am a hospitalist and do hospital medicines, see younger patients. But I think the same way.

Stephanie: I think what's interesting here is about this article that's bringing this up is that I think what we really need to think through is how do we teach this thinking? Not that, "Oh, should I order it or not?" But, "What are the circumstances where I would order this test, and what are the circumstances that I wouldn't?"

Stephanie: Sometimes that's evidence; sometimes you're in an evidence-free zone. Sometimes patient's goals are in there. Symptom burden, health system burden, all kinds of things weigh into those decisions.

Stephanie: I think we need to encourage residents to start talking through, be maybe more explicit about what are the reasons to order this test? And what are the reasons to not order this test? And what is the best outcome? What is a likely harm? How likely is that harm? Et cetera.

Stephanie: And starting to talk through these issues, rather than "Oh, we think they have pneumonia. Maybe order the chest x-ray." Be a little bit nuanced about what's going on in our head, because I think that's the only way they're going to learn this gray area where we exist.

Vinny: Absolutely.

Matthew: The thing that I just keep thinking about is, and I think we would all agree about this, is just the notion that in the decision not to do the things, we have to be just as rigorous, if not more rigorous in our decision making and the nuanced thinking.

Matthew: I think that these ideas, like "Less is More," or "Choosing Wisely," start from an evidence base that is very rigorous. But sometimes in the article, the example you're giving, that they're being used in a more flippant way.

Matthew: But the rigor has to apply both when you're ordering the test. But just as equally I think in geriatrics, when you decide not to do things we're thinking about, what are the downstream consequences? What is going to happen with the result here? That is a very rigorous process as well.

Stephanie: Yeah, I would say the decision to do nothing is probably one of the most complex decisions that you could make. So instead of it being ... and what you're seeing is students who are being intellectually lazy and not trying to make that decision.

Stephanie: But when you see that, doing nothing actually involves a lot of complex decision making. It's one of my favorite ... The reason I love geriatrics is because nothing is black or white. Right? You get to tease out all of these little details to decide and work with the patient and family to try to decide what is best here.

Eric: I think this is the hard part, is that what I'm also hearing from you, Stephanie, your doing nothing is actually doing a lot.

Stephanie: A lot.

Eric: So you're maximizing a lot of things.

Stephanie: Yeah.

Eric: Including not getting a UA or culture; you're working up other things, and not falling down potentially a red herring path where a culture's going to come back positive, and we're going to feel like we need to treat it.

Eric: Where some other ones, you are going to be checking those things. So I think that's the challenge; whether or not we're using words like "minimizers" or "maximizers" or "do nothing" is, that they don't actually adequately convey the challenge of both the diagnostic decision making and the therapeutic decision making.

Vinny: I think that's why it's important to really think about spotting minimizing behavior. I think as Chris mentioned, by and large, the problems that you are describing are still issues that we all face in hospital medicine. Which is tackling overuse and inappropriate use and waste.

Vinny: However, I know some of you have been to the Society of Hospital Medicine meeting, and there's poster after poster and initiative after initiative talking about improving waste and reducing inappropriate stop and choosing wisely.

Vinny: And it's in that context that at least, I think, what we are describing is this new phenomenon of people hiding behind the movement as a way to justify their minimizing behavior.

Eric: That's why I love your article, too. I love articles that challenge past notions and make us think. I think your article does a great job of just making us think.

Stephanie: Yeah, absolutely.

Alex: I see this as well in palliative care. It's a little weird when you're a palliative care consultant, and you're like, "No, you really should get that CT scan."

Stephanie: Yeah. We do that in geriatrics, too.

Alex: No, yeah, they have pain, yeah, they have pancreatic cancer. But there's something else going on here.

Stephanie: But I mean, that's the nuance of what we do, right? Overtreatment versus undertreatment. I'm thinking about that on every single patient, and you're always walking that line. Yeah, you see the same thing where they're like, "Oh, yeah, I was going to discharge this patient." I'm like, "Hang on a second."

Eric: Right.

Stephanie: They're like, "They're really sick right now."

Eric: Yeah.

Chris: Stephanie, you got at it when you said, what we're trying, this is the clearest way to say it, I think. You don't want the lazy thinking.

Stephanie: Right.

Chris: It doesn't mean doing more, doing less, doing ... The point was, minimizing, is our point, is lazy thinking.

Stephanie: Right.

Stephanie: Exactly.

Chris: It's not focused on what's right for the patient, it's not focused, and it's lazy thinking, perhaps because of lots of things. Because you're overwhelmed, because you're burned out, because there might be, there's systemic reasons why that may or may not happen.

Chris: But that's the area where the attending needs to say, "Wait a second. This is not in the best interest of the patient. It's lazy thinking, and you're just using a socially acceptable way to feel good about that."

Vinny: I definitely think that the lazy thinking, it's very interesting. You need time to think, and you need the capacity to think. And you need the mental space to think. We didn't talk a lot about this whole concept of burnout and well being.

Vinny: But I also think that as another meta-trend playing in, which is I've particularly seen this one. Residents are burned out. Maybe huge number stretches of inpatient; and why does this set up?

Vinny: Well, if you think about it, doing less is easier. All of a sudden, you can look like you're practicing high-value care, you have this great justification, you're doing less, it's less work for you. But it's not right for the patient.

Vinny: And I think that's been also an "aha" moment for me, which is that it's not about whether somebody's a minimizer. It's like, "Okay, you see minimizing behavior. Ask more questions."

Vinny: Why did they want to push that patient out of the hospital, or why didn't they want to order a renal consult for somebody who's had a doubling of their creatinine for no unexplained reason?

Vinny: I think those are the questions which is, where has your intellectual curiosity and your passion for helping people gone, such that you're saying, "Oh, we don't need to work this up." When in fact, you do.

Eric: Yeah, I love the idea of the doing less. I can see it both from the minimizer and the maximizer, who just will order all the consults so they don't have to work it up and think about the case, or order every test so they don't have to think about it.

Eric: And the idea of the intellectual laziness ... Laziness is probably not ... We all use shortcuts all the time. Using them appropriately and the concept of wellness and resiliency, too, around this. Maybe that's the potential issue on either end of the spectrum.

Eric: Well, with that, I really want to thank you for joining us on this podcast.

Alex: Thank you Vinny, thank you Chris.

Stephanie: Yeah, thank you.

Eric: I always learn so much from you guys.

Vinny: We learn so much, too.

Chris: Yeah, if nothing else came out of publishing this, I can hang out with you guys and rock out. It's been fun.

Eric: Well, how about we rock out a little bit more? How about we get a little bit more Devil Goes Down to Georgia? Did I do that right?

Alex: Devil Went Down to Georgia.

Eric: Can we change it to Devil Went Down to Austin?

Stephanie: The Devil Went Down to Austin.

Alex: (singing).

Stephanie: We ended on a good note.

Alex: Yeah, we ended on a good note. Oh, boy. Well, I got like half the lyrics.

Stephanie: South by Southwest, here we come.

Alex: My favorite line there, I stumbled with it.

Chris: Yeah.

Alex: "Chicken in the bread pan, peckin' out dough. Granny, does your dog bite? No, child, no."

Eric: No, child, no.

Alex: Where did that come from? I love it. I love it!

Eric: Well, Vinny and Chris, and Stephanie, thank you for joining us today. Really appreciate all of our listeners who are joining us as well.

Eric: Again, if you haven't had the time to actually share this podcast with your friends, colleagues, or review us on your favorite podcasting app, please take a minute to do so. We always rely on the generosity of our listeners to spread the good news of GeriPal.

Alex: Thanks folks. Until next time. Bye.

Stephanie: Bye.



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