Month: March 2013

How to Truly Inspire Interdisciplinarity: Lessons From a Cambridge College

Published on by Elizabeth (Liz) Dzeng3 Comments

Studying at Cambridge, I have had the privilege of drawing inspiration from the familiar and routine. I am fortunate that my workspace is across from the breathtaking King’s College Chapel. Just looking up and seeing the calmness and majesty of this architectural masterpiece washes away any momentary PhD setback. My walk to lectures takes me by the pub where Watson and Crick celebrated their discovery of DNA and J.J. Thompson discovered the electron. My bike ride home runs through the field where the rules of football were invented.

But what makes Cambridge an incredible place is the casual and natural interdisciplinarity that is unavoidable and fully ingrained into its social fabric. Student life is focused around the colleges; the dining hall, bar, and common areas are the nexus of the Cambridge experience. This is unique amongst post-graduate experiences in higher education. In most universities, social interactions are centred around one’s academic department.

In Cambridge, students hang out with people from every discipline from scientists to the social sciences to artists. Graduates and faculty at Cambridge colleges live, eat, and work together. They have offices in both their department as well as in their college, and they work with colleagues in other disciplines in college committees and councils. This creates a community that fully embodies the notion of working together as academics and intellectuals, rather than as a biologist, an architect or a historian. When disciplines mix organically, you develop new ideas and perspectives, as well as a flexibility and acceptance for other ways of thinking.

Looking back over the past few years, my most profound and influential educational moments occurred not in the classroom, but over meals, casual conversations, and at the pub. It was here in Cambridge that a good friend with opposing political views, but a ready willingness to engage in thought provoking debates, taught me how to hold my own in casual conversational debates on current affairs. It was in the King’s College bar where I first understood the fundamentals of Marxism over a pint with an anthropologist friend. Random discussions with a friend studying architecture resulted in our creation of a medical hypothesis to explain stigmata in Christianity. The most engaging discussion I’ve ever had about my PhD project on Do-Not-Resuscitate decision-making was with my philosopher and historian friends debating the moral philosophical aspects of autonomy and suffering. And a central influence in my desire to engage the public with my academic research developed through conversations with a friend who studies the Sociology of intellectuals.

These defining moments left me unsatisfied with a purely clinical career path. Residency training following my MPhil was at times a frustrating experience, as I could not help but think about all the structural problems that hindered my ability to properly care for patients. It was infuriating to only be able to put plasters on the acute issues that only temporised deeper pathologies that could only be fixed if we addressed the underlying problem such as lack of insurance, poverty, and skewed economic incentives in medicine.

I found it repressive to be so inspired by events such as the Arab Spring, only to go to work in the hospital and not hear a single mention of these events. I yearned to be back in Cambridge, where I could discuss the implications of the day’s events with my friends in Middle Eastern Studies and International Relations. It also reminded me of how far I had come. I recalled walking into work one day during medical school and someone telling me, “Al Zarqawi is dead.” I looked up at the patient census and asked, “What?! Which patient was he? What did he die of?” I was so immersed in medicine at the time that I had no conception of what was going on in the outside world.

Interdisciplinarity is the new buzzword in academic research and education. But few universities are able to pay more than just lip service to this concept. Indeed, the very nature of academia resists interdisciplinarity. We are trained to become experts on the most minute aspects of our subject, and are chastised for being too broadly focused or having too many interests. As Simon Goldhill, Director of the Cambridge Centre for Research in the Arts, Social Sciences and Humanities (CRASSH) states, “We have people who know more and more about less and less. That’s the definition of a PhD, isn’t it?” This intense specialisation prevents us from seeing the forest amongst the trees. It is thus completely unsurprising that cross-disciplinary efforts and inter-departmental initiatives often fail and do not go beyond initial superficial connections. I have heard gripes at more than one prestigious institution about the impenetrable silos that separate departments and communities within the university.

A common reminisce about college is the spontaneous philosophical conversations that occur in dorm hallways until 3 am. It is unfortunate that in most institutions of higher learning, we stop talking to each other after undergrad. Instead, we compartmentalise ourselves off in our departments, talking to people who think the same way we do. We begin preaching to the choir and feel affirmed that our style of thought is the only right way. The way in which we are trained and specialise shapes our identity and how we process the world beyond our academic disciplines.

Not only do we develop specialised knowledge, but we also become inculcated in a particular way of examining and talking about the world that breeds distrust against other approaches and a belief that our methodology is the best. I have felt for example, that some academic physicians on the surface embrace the concept of applying social sciences to medicine, but are unable to accept non-positivist ways of understanding the world and dismiss it as insufficiently rigorous. Joe Henrich, an anthropologist, used game theory rather than the more traditional ethnography to elucidate cross-cultural differences in gift giving and human behavior. Rather than embracing the capacity for other fields to enhance understanding, many anthropologists felt threatened by this methodological promiscuity, finding it “unethical,” “heavy-handed and invasive.”

I think a key aspect to achieving substantive interdisciplinarity is through the intentioned design of physical and social spaces. Creating spaces where people continuously come into contact with people outside their discipline in natural, casual social settings over and over again, helps develop social networks that eventually become the source of intellectual inspiration and creativity. Here is where “nudge” can be applied, where calculated use of space have the power to change human behavior and promote unconventional social interactions and networks.

Stanford has been a pioneer in designing physical spaces to foster mixing of ideas and philosophies. The Center for Clinical Sciences Research (CCSR) building has few walls. Instead of lab bench space being allocated by research group, where all members of a lab are grouped together, scientists are interspersed around the entire building, promoting collegiality and discussion amongst members of different labs and disciplines. Its intentions were clear from the start, “its design responds to emerging trends for interdisciplinary biomedical research, [where] interaction between disciplines and individuals is encouraged.” Bio-X’s Clark Center is another example of interdisciplinary spaces, where “warehouse like lab spaces and shared facilities” foster collaboration between engineers, scientists, doctors and others to develop technologies and solutions to a common problem.

At Stanford, I participated in a program called the Biodesign Innovation Program, which brought together engineers, business students, and medical students into small teams to come up with solutions to medical problems. My team invented a device, which we’ve since patented to minimally invasively cool the heart during a heart attack. The experience emphasised the ability of different perspectives to develop innovative solutions to existing problems. The Stanford d.school (Institute of Design) is the latest example of innovation in interdisciplinarity, where students from any department are able to take classes in applying concepts of design to their specific areas of research.

Michael Bloomberg recently announced a $350 million donation to the Johns Hopkins University, the largest donation of its kind to a university. He stipulated that a portion of this donation go towards endowing professorships focused on collaborative interdisciplinarity. I would urge Mr. Bloomberg to also encourage Johns Hopkins to think about new ways to nudge scholars out of their comfortable silos through design strategies that bring researchers of different subjects together. It would be amazing if new developments on campus grouped people in innovative ways, perhaps by problems to be solved or themes to explore, rather than by discipline. Programs similar to Stanford’s Biodesign Innovation Program would further bring together researchers, but perhaps more importantly, social spaces should be created which foster collegiality, trust and personal connections.

Many medical school campuses, including Johns Hopkins, are miles away from the main campus, preventing easy interactions between these campuses. Obviously it would be unfeasible to change this, but future buildings could be strategically located in ways that foster cross-disciplinary interactions. The Hopkins Bio Park is currently under development. Why not introduce buildings that house academics in medicine, humanities and social science who work together and research together as equals the intersection between medicine and the social science?

Princeton and Yale have collegiate systems modeled on those of Oxford and Cambridge colleges, where undergraduates live and socialize together in colleges. Neither graduate students nor faculty members are integrated into the college system. The colleges primarily provide residential and social support, rather than academic enrichment. I believe that these institutions have missed out on a critical aspect of the “Oxbridge” college system. Integrating the remainder of the university population into the college structure would enhance interdisciplinary interactions at the graduate and potentially faculty level. This is key because it is at the graduate level where we start becoming specialised and indoctrinated into the academic mindset.

I am leading a conference in Cambridge called the Global Scholars Symposium, which brings together students for three days of cross-disciplinary discussion with leaders in the field to discuss global problems, and how we can apply creative solutions to these issues. Participation in this conference in past years inspired me to continue looking outwards beyond my field to think about what we as young individuals can do to make the world a better place. Creating more opportunities that bring together scholars from different fields would hopefully inspire academics to look outwards beyond publication counts and grant writing to see how their research can be applied to solving real world problems.

Taking the interdisciplinary path has not been easy. Residency would have been far easier if I wasn’t always frustrated by the social and political problems which got my patients in the hospital in the first place, and hospital financing practices which at times seemed to prioritize the bottom line over patient care. I sometimes envied my colleagues who were singularly focused on becoming cardiologists so that they could focus on repairing valves. In my PhD research, I am constantly admonished for being too unfocused, and the desire to meld divergent discourses and epistemological stances has been fraught with challenges and misunderstandings. Hopefully in the end, I will be able to say that it was worth it and there will be a role for someone like me when I’m done with this chapter in my intellectual development.

A version of this essay was published in the Guardian on 15 March, 2013

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How Much are Misaligned Incentives in Health Care Costing Tax Payers?

Published on by Elizabeth (Liz) Dzeng

On Christmas Eve, I took care of a patient who had just undergone surgery for an infected artificial shoulder. He was to be discharged on intravenous antibiotics three times a day for six weeks. This is a pretty common treatment. Patients are generally able to give themselves this medication with the help of a home care nurse who visits once a week. The total cost of this is approximately $7000 for nursing visits, antibiotics and supplies ($120 per visit for eight nursing visits plus $143 per day for antibiotics)

The social worker informed him that Medicare would not pay for home care nurse visits or supplies. BUT, Medicare pays for inpatient rehabilitation, which he would be eligible for to receive these antibiotics. Given the choice of paying $7000 for home administration versus $0 for inpatient rehabilitation, naturally he chose inpatient rehabilitation.

The problem is, is that his inpatient stay costs taxpayers approximately $21,000. $350 for room and board plus additional costs for antibiotics and supplies, totaling approximately $500 a day. Furthermore, although he was well enough to be discharged home before Christmas, he needed to stay until he could be placed in rehab. Because of holiday scheduling, most rehabilitation facilities were not accepting admissions. Thus, he had to stay in the hospital an extra four days in the hospital over the weekend and holidays. Given that the average cost of a hospital stay is $2338 in Maryland that added an additional $9352 or so of unnecessary expenses.

In sum, because financial incentives encouraged my patient to spend $0 rather than $7000 out of pocket, Medicare spent an unnecessary added $30,000 on his hospitalization and care.
To make matters worse, my patient didn’t even want to go to rehabilitation. He preferred to administer the antibiotics himself at home and found it hugely inconvenience to have to be an inpatient for six weeks just for antibiotics. He was a small business owner, and these extra days in rehabilitation would hinder his productivity at work. He was upset that he had to stay in the hospital over the holidays for unnecessary reasons. He was upset about this twisted logic, which forced him to choose the less resource efficient option and lamented the financial burden he was unwillingly imposing on taxpayers.

This decision would harm my patient in other ways. Medicare limits beneficiaries to sixty lifetime days of inpatient rehabilitation care, so if he ever needed future inpatient care, he would have fewer days available to him. Staying in a hospital facility can also be harmful medically, as added days in the health care setting place him at increased risk for health care acquired infections.

The United States has been in recession for years and calls for fiscal responsibility ring loudly. Fiscal crises and congressional deadlock have almost become the new normal. Rising health care costs account for 25% of total federal spending and stands at $2.8 trillion a year. This contributes a significant portion of our national debt at a time when we can’t afford wasteful spending.

The Affordable Care Act has attempted to curtail waste through various mechanismsincluding redirecting care from high cost specialists to lower cost primary care doctors, restructuring reimbursement from fee for service to a value based model. Others have suggested various cost cutting mechanisms such as reducing overtreatment, implement market-based incentives, and reduce overhead.

My patient’s situation illustrates another aspect of potential cost control that has not frequently been discussed. Skewed financial incentives caused by illogical Medical reimbursement schemes create additional unnecessary costs that are not just wasteful, but also harmful and inconvenient to patients. $30,000 is a great deal of money to waste on something that is medically unnecessary and unwanted.

This is but one example where misaligned incentives drive providers and patients to choose the less efficient, more wasteful option. Examples are abound in health care. Patients in New York regularly told me that they called an ambulance because it was cheaper to them (free!) than a $20 cab ride. An ambulance ride in New York City costs $704 per ride not including mileage. Medicare and Medicaid contribute approximately half of the FDNY’s total revenue of $205 million yearly.

I remember referring one of my clinic patients to the social worker because she had recovered from depression and wanted to get a job. The social worker discouraged her from finding employment and instead advised her to volunteer because she would lose her disability benefits if she found gainful employment.

Because uninsured patients do not have outpatient drug coverage, it is not uncommon for uninsured cancer patients to be admitted to the hospital in order to get outpatient chemotherapy infusions. This adds approximately $2338, the average cost of an overnight admission, on top of what would have been an outpatient infusion.

I could go on and on.

Policy changes that systematically reform these misaligned incentives could do much to reduce illogical decisions that cause wasteful healthcare spending. Lobbying and patchwork legislation have led to our current system of fragmented reimbursement schemes where benefits initially meant to help patients, create unintended consequences leading to wasteful spending. Long-term solutions to counteract our increasing federal deficit require bending the cost curve of health care. Taking a careful look at Medicare reimbursements that don’t make sense could potentially save millions of health care dollars and improve quality of care.

Special thanks to Donald List, LCSW-C, for assisting with obtaining the costs of the therapies and services mentioned in this article.

Originally published on thehealthcareblog.com on February 23, 2013

The Hippocratic Paradox: When Is Resuscitating a Patient Doing Them Harm?

Published on by Elizabeth (Liz) Dzeng5 Comments

A 52-year-old woman came into our hospital in New York bleeding to death.

She had advanced stage throat cancer. Her tumor, on the left side of her neck, was both pushing into her airway and a major artery. As the tumor grew, the woman could no longer breathe, and when her artery ruptured, blood started pouring into her lungs.

She would die by drowning in her own blood.

Her husband was understandably overwhelmed and distraught. He instructed us to take any measures possible to keep her alive. She was too weak to contradict her impassioned and dedicated husband.

This was, in my view, the wrong choice from an ethical and clinical perspective. How could I uphold my oath to do no harm when I knew she would die a particularly gruesome death, and I was instructed by her husband to keep her alive and in this state? I would have to crack her ribs during chest compressions and electrocute her to attempt to restart her heart. Regardless of whether we could keep her heart beating, the rest of her body would still be irreparably consumed by cancer. It was anguishing to be forced to inflict this sort of violence on this dying woman.

Recently in the UK, a patient’s family took doctors to court claiming that doctors at the Addenbrookes Hospital ‘badgered’ Janet Tracey, a 63-year-old woman into agreeing to a Do-Not-Resuscitate (DNR) order and ultimately instituted it without the family’s permission. She had fractured her neck in a car accident shortly after she was diagnosed with terminal lung cancer. The controversy surrounding the incident spotlights questions of whether there is a legal duty to inform and consult patients on DNR decisions, and whether patients should have the right to demand resuscitation.

The courts decided the case should not go forward to judicial review, thus reaffirming that the decision to pursue CPR should be based on the doctor’s clinical assessment of what is in the best interest of the patient. I believe that it was the right decision. CPR is not always the life saving procedure that one typically sees on television. Outcomes in patients who are in the last stages of a terminal illness are extremely poor and prolonged oxygen deprivation during CPR frequently results in irreversible neurological damage.

The debates surrounding this case reflect a rightful demand for greater control in personal health care decisions and enhanced communication between the provider and the patient. But, as was the case with the woman in New York, I have seen countless situations in America where physicians are put in the ethically uncomfortable position of having to aggressively intervene upon a patient they believe have no chance of survival.

In the US, any decision to institute a DNR order must come from the patient, his family, or appointed surrogate. While this gives families a sense of control and decision making capacity over their loved one’s care, it also places a significant burden of guilt onto them. They are forced to make decisions that aren’t actually choices. I found it cruel to have to ask families already suffering emotional trauma to ‘refuse’ this useless procedure. Not only does it create false hope, but it also makes families feel as if they’re having to decide whether to give up on their loved one. When the end of life is inevitable, it is God or nature who decides, not doctors or families.

An essay by Ken Murray, an American physician, entitled ‘How Doctors Die’, resonated deeply amongst the American medical profession. He recognized that when it comes to themselves, most doctors do not want to be subjected to “futile” care. They know modern medicine’s limits and its ability to subject our loved ones to “misery we would not inflict on a terrorist.” Medical decisions to withhold CPR do not occur because doctors have given up, but instead from efforts to prevent unnecessary suffering at the end of life.

Unlike the US, here in the UK the ultimate decision regarding resuscitation lies with the doctor. The UK General Medical Council stipulates that doctors are not obligated to provide treatments at the end of life, including resuscitation, that would not be clinically appropriate or of overall benefit. This guidance reflects the position that these are clinical decisions; patients may not demand treatments that physicians believe would be futile or would not result in a meaningful prolongation of life.

The recent focus on autonomy over decisions at the end of life in the UK, through Tracey’s court case as well as controversy over the Liverpool Care Pathway, highlight the need for continued dialogue and clarity on these issues. The lawyers involved in the Tracey case have rightly affirmed that these decisions should not be made in the courts – a process that encourages suspicion and public anxiety.

Instead, we should work together to foster trust and confidence in the health care system, by encouraging conversations about resuscitation decisions at all levels. The NHS’s Dying Matters initiative has already pioneered efforts to change public perceptions of dying and counter unrealistic expectations. Future guidelines should be established through public consensus between practitioners who have professional expertise in this area and key stakeholders.

I feel that the UK is at a crossroads in much the same way that the US was several decades ago. High profile court cases surrounding patient rights at the end of life catalyzed a set of changes, which led to America’s current system of aggressive treatments at all costs regardless of futility or clinical common sense. I encourage my British colleagues to looking across the pond to the US as a cautionary tale of how these decisions impact our ability to serve in the best interest of our patients.

Published in the Huffington Post on January 18, 2013