Steven P. Ringel, MD, FAAN, has recently written about changes in teaching rounds over the past 40 years (Neurology® 2009: 72: 2049-2051). AAN.com asked Ringel to comment on the changes he has noted. He spoke with Daniel B. Hier, MD, MBA, FAAN, AAN.com Associate Editor for Education.
AAN.com: What is the greatest deficiency in neurologic training today?
Ringel: Neurology, along with almost every other medical specialty, has failed to provide trainees with probability and cost-effectiveness data. Trainees are given long lists of differential diagnoses and feel obligated to order tests to rule out all possible diagnoses, even though the likelihood of some is remote. Residents as well as most of their teachers have no idea of what things they order cost and which approaches are the most cost-effective. With rapidly escalating health care costs, we have to think more about efficient management of patients and need better comparative effectiveness data.
AAN.com: How do we try to make residents aware of how much care costs?
Ringel: I feel strongly that physicians are wasting a lot of money in medicine, not because they are greedy, but because they haven't been taught how to practice cost-effectively. I keep emphasizing that if we rein in what we order, then money can be reallocated for what we do best—seeing patients. Unfortunately, there have been few comparative effectiveness studies to date and there is an immediate need for reducing costs. For every patient encounter, neurologists have to make their best estimates of what to eliminate or modify, and educators have to insist that resource recommendations become a high priority. Down the road we can rely more on outcomes studies to verify or amend these transitional approaches.
AAN.com: In your article, you mention a patient with a movement disorder who defied diagnosis, despite exhaustive testing. Has the availability of testing made us too dependent on testing to get to the diagnosis?
Ringel: The hidden message in our curriculum is "don't miss a diagnosis." Neurologists in practice trained in that environment order far too many tests. It's not uncommon for patients who are referred to me for a second opinion to have already undergone numerous imaging studies and laboratory tests—even though they have a normal examination and would benefit most from reassurance. Paradoxically, the more we test, the more we uncover "incidentalomas" that raise patient anxiety and often lead to unwarranted treatment or even unnecessary morbidity.
AAN.com: You mention a patient in your article that may have had a migraine, yet was treated with tissue plasminogen activator (tPA) for possible ischemic stroke. The vignette raises the delicate issue of distinguishing between following the correct guidelines and doing the correct thing for the patient. How can we address it?
Ringel: Human variability makes it impossible to treat all patients exactly the same. But that is no reason to completely ignore guidelines of care. For too long, physicians have insisted that no one can possibly tell them how to manage their patients. The result is huge variation in care across our country. How do we reconcile that with what should be a common neurologic curriculum? It makes sense to insist on greater standardization of care with the understanding that guidelines have enough flexibility so that "one size does not fit all."
AAN.com: Do you worry that the accelerated pace of medical care has created inefficiencies or even dangers?
Ringel: Today's telescoped care is often to the detriment of patients. Our payment systems encourage churning—see patients faster and discharge them more quickly. It's a counterproductive strategy that is exhausting for doctors and unsatisfactory for our patients. I'd much prefer it if I were paid to spend more time with patients. Isn't that what you would want if you were seeing a neurologist?
AAN.com: You make the point that we often spend too much time treating the disease and too little time treating the patient. Is it unrealistic to expect neurologists to take care of the whole patient, given the complexity of their medical and social problems?
Ringel: Unfortunately, our current reimbursement system rewards us for doing things rather than talking to patients. For patients with chronic neurologic disorders, a neurologist who does not understand the complexity of her patients' medical and social problems will not be effective in discussing difficult options with her patients.
Although neurologists are certified by the American Board of Psychiatry and Neurology, very little of their formal education addresses psychiatric approaches for managing human behavior. Francis Peabody is famous for having said, "The secret of the care of the patient is in caring for the patient." Seasoned clinicians understand that it takes time to get to know patients and to educate them.
AAN.com: Is that something we can teach?
Ringel: I urge residents to imagine themselves in the shoes of their patients. Then ask, what do you want the neurologist to explain and what can he do to help you? After all, at some point you may be discussing life-threatening issues with them.
AAN.com: You point out that for many patients uncertainty of diagnosis is a necessary reality. Is humility about what we know something you address during rounds?
Ringel: I try to explain to residents that patient encounters with a neurologist are not isolated events; rather, our diagnoses and recommendations often evolve over time. We all have to learn to be more comfortable with ambiguity in working with patients. Unfortunately, much of neurologic education still occurs in inpatient settings where residents are not exposed to continuity of care. It's very beneficial for residents to follow patients with ambiguous diagnoses serially so they can gain that experience.
Dr. Ringel has nothing to disclose.
Dr. Hier serves as Education Editor for AAN.com and is Director of Physician Practice for the Neuroscience Center of the University of Illinois at Chicago. He has received compensation for work as an expert witness in medical legal cases. Within the last 24 months, he has received compensation as a physician editor for the Neurology edition of MDnetguide.