“The emergency care world is a microcosm of so many issues that challenge health care delivery today—cost, efficiency, tradeoffs, quality and safety, communication, local versus regionalized care and disaster preparedness.” So says Zachary Meisel, M.D., Robert Wood Johnson Foundation Clinical Scholar and, as of January 2011, a regular contributor to TIME.com’s heavily trafficked Health & Science Web site.
In his “Medical Insider” columns, Meisel breaks down some of the mysteries of emergency room decision-making, explaining what goes into the choices doctors make. Along the way, he takes on pressing issues in health care, and highlights the importance of research and its real-world applications.
Among the topics he’s addressed so far: disaster preparedness, the unintended consequences of health information technologies, Google-assisted self-diagnosis, why belly pain is difficult to diagnose and what that means for the methods and cost of care, why doctors sometimes over-order tests, why doctors test patients for illegal drugs without consent, and more.
Meisel draws liberally on his own experiences as an emergency physician at the University of Pennsylvania. In his column on health information technologies (HIT), for example, Meisel embraces new technologies and the many advantages they offer. But he tells a story about his own experience to highlight the unintended consequences:
Not that long ago, if I ordered an X-ray on a patient, I had to walk into the radiology-reading area to look at it. Often there would be a radiologist sitting there in the dark room; we would talk about the patient in a way that would often lead to closer examination of one part of the X-ray. Sometimes this conversation would lead to a cooperative reconsideration of the findings. But now, unless I have a specific question or concern, I don't have to go back to the radiology reading room— HIT allows me to look at both the X-ray and the radiologist report almost instantly on my desktop computer in the ER. Sure, it is efficient and helps me see more patients and spend more time on other emergency tasks. But the result, I worry, is that I may be more likely to miss something important.
In a separate column, Meisel joins with Jesse Pines, M.D., M.B.A., M.S.C.E., to addresses the increasingly common use of CT scans and MRIs, and the implications for the cost of health care. They note that such tests have “dramatically changed how patients are diagnosed and treated,” observing that as recently as ten years ago, patients would undergo exploratory surgeries to diagnose conditions that a CT scan might lay bare today. But the scans are expensive, and not without risks to patients in the form of substantial radiation and false positives. A common explanation for the now-routine—and in the view of many, overly so—use of these technologies is that doctors are practicing “defensive medicine,” ordering unneeded tests simply to preclude malpractice litigation. But Meisel and Pines write:
Another reason for over-testing is simply that new doctors can't function without them. Lately, radiology tests have become a crutch: doctors in training are no longer taught how to distinguish patients who need testing from those who don't. A decade ago, a surgeon would spend time interviewing and carefully examining a patient to help decide if he or she needed a CT. Now, many surgeons, especially the younger ones, won't see a patient until the CT is complete. Testing has become more of a reflex than a higher-level decision.
Meisel has published frequently in academic journals, as well, and he cautions that writing for a more popular audience does not require simplistic topics or argument. “One thing I have learned is that lay audiences seem to really embrace nuanced and complex issues related to health,” he says. “It doesn’t always have to be black and white.”
He notes, too, that the TIME.com column is a chance to communicate the critical value of research to a broad audience. In one column, for example, he notes that while emergency room staff are wary of patients who self-diagnose by means of a Google search, researchers and medical educators regard the conversations that such self-education helps start as a good way to get patients to partner with their doctors in making decisions about their care.
Meisel says his participation in the RWJF Clinical Scholars program “has given me the tools to think critically about health policy and health services research. RWJF has supported me in this endeavor, I think, because we have similar goals: to make sure that research doesn’t get stuck in a vacuum, and to disseminate and translate important concepts in a way that has the potential to improve health.”
For more than three decades, the Robert Wood Johnson Foundation Clinical Scholars® program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policy-makers on issues important to the health and well-being of all Americans.