When Research and the Realities of Practicing Medicine Collide
September 7, 2023
Photo by Dhanya Kumar
Tradeoffs research reporter Soleil Shah recently added a new role to his resume: first-year medical resident. Dan talks with Soleil about what he’s learning in the hospital about the value and limitations of health policy research.
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Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!
Dan Gorenstein: There’s this idea in medicine that if more doctors just followed the data, they’d deliver better care and waste less money. Easier said than done.
That’s just one of the many lessons new first year medical resident Soleil Shah has learned in his first few months on the job. Soleil also writes Tradeoffs’ weekly newsletter Research Corner highlighting interesting new health policy studies.
Today, how one young doctor is navigating the huge and ever changing body of evidence on everything from patients unmet social needs to suicide screening. From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.
DG: Soleil, welcome. Nice to have you here.
Soleil Shah: Thanks, Dan. It’s really good to be on the show.
DG: So you’ve written over 20 Research Corner columns, Soleil, on topics as thorny as whether doctors should treat opioid addiction remotely, Chat GPT and its growing role in medicine, and the cost of new Alzheimer’s drugs.
And I personally really like how you’re breaking these studies down, but I’m also super curious whether these wonky papers influence you as a doctor, like change how you treat patients. And I know you’ve brought in two papers to talk about and the first one is about meeting a patient’s social needs, right?
SS: Yeah, that’s right, Dan. So one I’ve been thinking about a lot is a paper I read back in June in JAMA by Sanjay Basu and colleagues that tries to put a price tag on patients’ social needs like housing, transportation and food, particularly for low income patients.
DG: I remember that one. It showed that patients have a bunch of unmet social needs, and while there is some government support, it is often not enough.
SS: Exactly. It found that big government programs like SNAP, Medicare and housing support cover less than half the cost of meeting someone’s needs.
DG: Got it. So the federal government pays for less than half. Is anyone paying for the rest?
SS: So there are sporadic grants, charities, local and state funding. But the researchers point out that this funding is usually really unreliable and lots of people who need things like housing assistance or food vouchers go without. And as you said at the top of the show, I’ve been a resident for about three months now, and I’m starting to meet more and more people who fit this description. So shortly after reading this paper, I met a woman who I’ll call Maria.
Maria is in her forties, has this horrible ovarian cancer. It spread throughout her entire body and fluids keep building up in her belly. It causes her so much pain and puts her at risk of all these infections. She’s basically getting her abdomen drained nearly every week.
DG: Sounds awful.
SS: It is. And one day I was in the room with her, examining her, and we ended up talking about her life for nearly an hour before she got cancer. Maria worked as a parking officer, but then she got the cancer and things really fell apart.
She couldn’t go to work. She got divorced and was basically living off of her disability checks. She ended up getting remarried, but she and her new husband now live in the top floor of this apartment. And with her cancer, it’s really hard for her to go up and down the stairs. It’s just super painful.
DG: Making it that much harder for her to make her doctor appointments and pick up medications, I’m guessing.
SS: Exactly. And this is where the study comes in. I can’t independently confirm this, but Maria told me she’s on a waitlist to get new housing.
DG: And if she had gotten that housing help, Soleil, arguably that could have really helped her take care of her health better, right?
SS: Yeah, exactly, Dan. As her physician sitting at her bedside, Maria is not in good health. Looking at her chart, she’s missed some appointments, skipped filling some prescriptions. She’s had 19 emergency department visits or hospital admissions since 2020. 19 visits in 32 months, Dan.
DG: Wow. I know from my reporting, anybody who goes to the ER and the hospital that much is really hurting.
SS: Yeah. You know, Maria is one of about 6 million people in the U.S. who are coming in and out of hospitals and ERs every year. Many of them are really sick and have some kind of crippling social issue. And this one-two combo is often leading them back into the hospital all the time. The whole situation made me wonder about the costs of not paying for Maria to get a first floor apartment, because at least in theory, if it was easier to be mobile, Maria could get to the doctor’s office, the pharmacy, get her tests done, and that could mean fewer ED and hospital admissions.
DG: Yeah, researchers and industry executives have been talking about this for years. Meeting a patient’s social needs could actually improve health and lower health care spending.
SS: That’s what was so interesting about this paper. Basu and his colleagues went ahead and put a price tag on how much it would cost to meet the social needs of people like Maria. And what they found is that it costs an average of $60 per patient per month to cover costs in four areas: food, housing, transportation and medical care coordination.
DG: And what did that make you think about Maria, Soleil?
SS: So, Dan, as a new doctor, I think about Maria, hearing her story, seeing this woman sometimes in agony and I’m wondering: What would Maria’s health be like [and] what would her life be like if someone spent 60 bucks a month on her social needs? Let’s say that prevented two hospital visits a year.
DG: Right. I mean, hospital visits are crazy expensive.
SS: Yeah, so to do some rough math here with what the average hospital in Massachusetts charges per day, avoiding two hospital stays could easily save $30,000 in health care costs. Definitely makes those 60 bucks a month seem like a pretty good deal.
DG: Right, this is part of what makes the focus on meeting patients’ social needs enticing and why so many people are invested in the topic — the prospect of spending more money on social needs to cut health care spending. To be clear, these sorts of approaches have a very mixed record of success.
SS: Yeah, I know, Dan, there are some interventions that might improve care for people like Maria but will not save money.
You wanted to know whether this paper changes how I am as a doctor. This paper reinforces my desire to think about the social needs of my patients and show up for them. One small thing I did with Maria was make sure she met with one of our social workers. Big picture: It’s clear to me we need some broad policy changes. But while we wait for that, I plan to keep talking with my patients, hearing their stories and figuring out what I can do to help.
DG: Okay, thank you, Soleil. And really thanks for taking us behind the curtain as a medical resident and all those uncomfortable or uncertain moments that you’re seeing along the way.
SS: For sure, it’s been a learning process.
DG: After the break, the latest research on when doctors should bring up suicide. And Soleil talks about the strengths and limitations of data.
DG: Welcome back. We’re joined by Soleil Shah, who writes Tradeoffs’ weekly newsletter Research Corner and is a medical resident in Boston.
A quick warning: The second paper that Soleil has brought in deals with suicide. If you’re having thoughts of suicide, call or text 988 to reach the Suicide and Crisis Lifeline.
Now, Soleil, for seven years doctors have been encouraged to ask patients in clinics — even those without any history of mental health conditions — about depression. There’s good evidence that those types of questions can help people who are depressed get treated earlier. What’s less clear is whether it’s also helpful to routinely ask patients about suicide.
SS: Right, Dan, and last month, the U.S. Preventive Services Task Force, an organization that issues influential guidances to clinicians about all sorts of medical screenings, said there’s not enough evidence to recommend asking patients about suicide if they have no mental health symptoms or history.
But other groups like the Surgeon General’s Office and advocacy groups, are still in favor of that sort of more universal suicide screening.
DG: Okay, so this really seems tricky. Soleil, just to start off, how have you handled the situation where you treat a patient who does not have any history of mental illness and they are not depressed?
SS: Well, I always ask about their overall mood and whether they are feeling depressed. But if they really say no to everything and have no past medical history of mental health issues, I usually skip asking asking any questions about suicide. And that approach was supported by these findings. Researchers looked at this big analysis of 27 different studies and found it doesn’t reduce suicide attempts or deaths and in some cases might even lead to some harm.
DG: Yeah, that surprised me. In your piece, you mentioned how health insurance companies can potentially use this kind of screening to deny coverage for medical care that is related to suicide attempts.
SS: That’s right. And you know, Dan, there’s another reason I’ve been reluctant to ask when I’m in the clinic as opposed to the hospital. There are really very few services we can even offer, and even if you refer a patient to therapy or a psychiatrist, they might not get seen for months.
DG: So it sounds like even at this early stage of your career, Soleil, you’re getting a handle on this. Only ask about suicide for those patients with some kind of red flag, at least in a clinical setting.
SS: Yeah, it’d be nice if it was that easy, but it’s not always so clear cut. There are times where I meet a patient with no depression symptoms, nothing with their mood and no mental health issues, but then they tell me something like their four year old daughter just got diagnosed with cancer and is probably going to die, or that they’re in an abusive relationship. And depending on how they say it and just the concern or look I see on their face, I sometimes worry a lot, Dan. I mean, I’ve had friends who’ve taken their own lives unexpectedly. What if I’m the last opportunity they have to share those dark thoughts with someone they can trust? And, you know, even in spite of this research, sometimes I ask because it just seems like the right thing.
DG: Fair enough. So that’s in clinic. What about the hospital?
SS: So at the hospital, I’m much more likely to ask patients regardless of their symptoms or history, even if I have the slightest concern.
DG: Just because you’re at the hospital.
SS: Yeah, my calculus really changes in the hospital because there’s so much more to actually offer the patients.
Back in July, I had this patient on my list we’ll call Vanessa — a woman in her forties with severe diabetes, unstable housing and a bunch of other medical problems. She’d come in a few days earlier for a pretty rough ulcer on her foot that had become infected.
I was doing some chart digging and saw a note from her nurse the day prior to my shift saying that Vanessa wanted to kill herself. But then I see the note from the overnight residents saying no suicidal ideation overnight.
“Which one is it?” I thought to myself.
So I’m walking to her room early in the morning and thinking to myself, “Should I ask her about suicide again?” Like, I’m about to meet this person for the first time. Does she need some random guy walking in there, waking her up at 6 a.m. and asking? And if I do, how do I even phrase it?
DG: And real quick, Soleil, the task force’s recommendations are silent on this kind of scenario, right? Like, how are doctors supposed to respond?
SS: That’s exactly right. And I’m telling you about this patient because I think this illustrates something I’m just beginning to realize: just how much a medicine is not based on evidence, how many areas you run into where there’s not great data or clear cut guidelines, but you still have to make a decision in that moment.
DG: And what did you decide?
SS: I asked her whether she was having suicidal thoughts.
DG: Why did you decide to do that?
SS: Well, when I walked into that room, it was just really sad. She had this massive foot ulcer that was exposed, all these tubes pumping medication and fluids into her veins, just looking totally defeated and worn. And you see this in the hospital a lot. But I just thought to myself, especially after reading her medical history, if I was in her position it’d be so easy to feel like I was in a dark place. And again, she’s in the hospital. There are psychiatrists, psychologists, social workers, addiction medicine experts who could all help her that same day if she needed it. So I just went for it.
DG: And what happened?
SS: I introduced myself and explained that I was her doctor for the day. We made some small talk, and then I told her what I had heard from the nurse and I was worried about her. Ultimately, I asked, “Are you having thoughts of wanting to end your life?”
She paused and broke into tears. She said no but told me she was anxious because of issues surrounding her housing and that she’d also been having horrible pain from her migraines. So I wrote all of that information down and I came up with a plan to get her social worker involved and get her started on some medications for her migraine. And Dan, I was honestly so relieved that something good came from me asking that question because I really didn’t know how it would go.
DG: It sounds like it went really well.
SS: I think so. And it definitely taught me another lesson. Sometimes the weight of the question itself, the gravity can get patients to talk about stuff that means a lot to them, but has been buried. And opening those doors can help expose the problems that I can try to address in the moment. Again, you wanted to know how these studies influence me as a doctor? Going forward, I’m going to keep asking those heavy hitting questions with patients — even those who I might initially have less concern about — at least until newer data or guidelines tell me otherwise.
DG: So taking a step back, Soleil, we’ve covered two interesting papers from Research Corner. What do you think these and really all the other papers that you’ve reviewed are teaching you as this new budding doctor?
SS: I think I’ve gained a new appreciation for this tension between the value of patient stories and anecdotes and the power of these larger scale studies. Those numbers and data are so important for helping us make sense of the anecdotes, like knowing if, for example, a service that might help Maria could actually save money if it was offered to every other American, too.
But on the flip side, as you try to apply the data at the bedside, I’m appreciating how strong the pull is to see each patient as a kind of “n of one” — a unique person with unique life circumstances. And there’s great value in that too — in not just blindly following the data, but in following my instincts and embracing that kind of human urge to meet each patient’s needs.
DG: It sounds like you’re saying there’s this needle you’re trying to thread: Follow the data, but also remember our humanity.
SS: Yeah, that’s exactly right, Dan. And you know, I think that’s a balance I’m going to be trying to strike for the rest of my career.
DG: Soleil, thank you so much for taking the time to talk to us on Tradeoffs.
SS: It’s been a pleasure, Dan.
DG: Check out the Research Corner newsletter at tradeoffs.org/research. It’s totally free and comes straight to your inbox every Tuesday.
And if you want to drop Soleil a line, please find him on X, formerly known as Twitter, @SoleilShahMD.
I’m Dan Gorenstein. This is Tradeoffs.
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Selected Resources from Tradeoffs’ Research Corner:
Screening for Depression and Suicide Risk in Adults (U.S. Preventive Services Task Force, JAMA, 6/20/2023)
Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care (Sanjay Basu, et al; JAMA Internal Medicine; 5/30/2023)
Soleil Shah, MD, MSc, Research Reporter, Tradeoffs; Resident Physician, Brigham and Women’s Hospital
The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode from Blue Dot Sessions and Epidemic Sound.
This episode was edited and produced by Dan Gorenstein and Soleil Shah, and mixed by Andrew Parrella and Cedric Wilson.