By Christopher Moriates, MD and Andrew Lai, MD MPH
University of California, San Francisco http://bit.ly/133FmnE
The daily “Resident Report” conference at the University of California, San Francisco (UCSF) started a little differently yesterday. The Chief Resident stood at the front of the room and asked the audience, “How many of you ordered labs for a patient this morning?”
Only 2 people in a crowd of more than 20 put up their hands.
Yesterday’s lab ordering restraint was not because of our focus at UCSF over the last two years on decreasing unnecessary services and costs of care, nor the fact that our Chair of Medicine, Dr. Talmadge King, has declared “Choosing Wisely” a Departmental priority. In fact, in 2010-2011, housestaff were offered an incentive of $400 each if they were able to reduce common labs by 5% — they didn’t.
At UCSF we have been exploring listing the prices of labs on order screens, much like was successfully done at Johns Hopkins. We have tried educational programs and feedback to reduce the costs of daily lab ordering, much like was described in the memorably titled research paper, “Surgical Vampires.”
So what finally got them to not order daily labs yesterday?
It was a strike by the patient care technical workers represented by the American Federation of State, County and Municipal Employees (AFSCME), in conjunction with a “sympathy strike” by the University Professional and Technical Employees (UPTE), which occurred at all University of California medical centers. This severely limited resources with virtually nobody in the hospital to collect and process labs. This created a situation where labs, along with imaging and procedures, could only be performed under truly urgent circumstances. As a result, our Chief Medical Officer reported that our medical center ordered less than half the usual number of labs.
Let’s be clear: this strike was not good for patient care and resulted in cancelled surgeries and chemotherapies, as well as the inability to accept inpatient transfers from community-based hospitals despite these patients needing specialized care. But if we are to find a silver lining of this strike, it did indeed serve as a teachable moment for forcing clinicians to think more thoughtfully about our diagnostic test patterns. Our medical service leadership counseled all teams to ask themselves “Does my patient need this test?” and “Is there another patient who needs this test more?”, simple questions that should automatically cross our minds every day in our daily work flows. It is possible that this two-day experiment may provide an impetus to ingrain this sort of reflective – rather than reflexive – ordering practices into the culture post-strike. At least for a few days it seemed to break the stronghold of routine daily labs.
After all, our Chief Resident asked a follow-up question to the “Resident Report” group yesterday: “How many of you felt that not ordering daily labs this morning impacted your patient care or outcomes?”
Not a single hand.
Christopher Moriates, MD (Twitter: @ChrisMoriates) is an Assistant Clinical Professor at UCSF. He is the Co-Chair of the UCSF Division of Hospital Medicine High-Value Care Committee. He works with the ACP, ABIM Foundation, and Costs of Care on educating physicians about healthcare value.
Andrew Lai, MD MPH is an Assistant Clinical Professor at UCSF. He directs the Division’s Case Review Committee and co-directs the Hospitalist Procedures Service. He is a member of the Division of Hospital Medicine High-Value Care Committee, Quality Improvement Committee, and the Global Health Committee.