番茄社区

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody, welcome to MedPod Today, the podcast series where 番茄社区 reporters share deeper insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

Today, we are talking with Kristina Fiore about "administrative harm." And then, I'll detail why there is no alternative to IVF -- despite what some GOP lawmakers say. And you'll definitely want to stick around for our final segment, where Michael DePeau-Wilson shares zebra tales. On to the show.

Administrative decisions can cause harm, both to patients and their clinicians, and doctors have known this for a long time. But now, a name for the concept is starting to stick: "administrative harm." It was the subject of a paper and an editorial in JAMA Internal Medicine last month, which Kristina Fiore covered, and she's here to tell us more.

Kristina, tell us about the rise of this term, "administrative harm."

Kristina Fiore: Yeah, so the term "administrative harm" was actually coined by Dr. Walter O'Donnell of Massachusetts General Hospital in a piece that he wrote in . About 10 years earlier, two researchers had described a similar phenomenon, but they attributed it to insurers and pharmaceutical companies. O'Donnell was truly the first to apply it to decisions made by hospital administrators and to use the term outright. It doesn't appear anywhere in the literature before his New England Journal paper.

The from this past June was led by Dr. Marisha Burden at the University of Colorado, and it was the very first to characterize administrative harm from a research perspective. Burden and her colleagues conducted a survey and held focus groups with more than 40 people. They were a mix of clinicians, administrators, and patients. And while only 6% of those folks said they were very familiar with the term administrative harm, 81% said they had felt they had participated in a decision that led to administrative harm.

Robertson: I imagine that doesn't sit well with doctors, especially.

Fiore: No, no. It definitely doesn't. Both Burden and O'Donnell told me that a major sticking point is that doctors are evaluated on almost everything they do. They're rated on productivity, on patient satisfaction, on procedural outcomes, whereas administrators, on the other hand, are rarely rated on the outcomes of their decisions, the researchers said. So another gripe is that the clinical arena is full of evidence-based practices, and there are guidelines for treating all manner of conditions, right, yet there are no evidence-based administrative practices.

Burden is working on that. She started an organization called Gritty Work, which is trying to get answers to questions like, 'What's the optimal patient panel size for a clinic?' and 'How many patients should a doctor see in the inpatient setting?' And on top of that, O'Donnell offered up some ideas for how to evaluate administrators on their outcomes.

Robertson: What are some of those ideas?

Fiore: So he said one metric could be clinician turnover, or attrition. Administrators should be rated on the morbidity and mortality of their staff, he said, and a part of that is, who is still here at the end of the year? It would be "really telling if there are very different rates for different administrators," he said. Burnout rates are another possible metric, but those, he said, are "crude and limited" because they're an "extreme event." Outcomes of decisions that meet a certain financial threshold could also be tracked, and that's another option, not just in terms of finances, because it always helps the budget, of course, but in terms of 'What did it do to the clinicians?' he said.

Robertson: It sounds like that would take a sea change. But Burden had some solutions that any clinician administrator could implement immediately, right?

Fiore: Yes, yes. So Burden herself is a clinician administrator, and if I were a healthcare professional, I feel like I'd want to work with her. She said that one strategy is taking an administrative time out, just as some surgeons do when they're running through a checklist before a major procedure. Another thing is committing to do look-backs so administrators can constantly improve and do better. And a third thing is increasing collaboration, where administrators, clinicians, and patients can all have a say in how deeply an administrative decision is going to impact clinical care.

Robertson: It sounds like we are going to be hearing a lot more about administrative harm in the future. Thanks, Kristina.

Fiore: Thanks, Rachael. I'll host the next segment.

Some Republican legislators are trying to direct federal funds to "restorative reproductive medicine," a so-called alternative to fertility treatments like IVF. The proposed legislation is called the RESTORE Act, which stands for Reproductive Empowerment and Support through Optimal Restoration. Rachael had fertility physicians break down these alleged alternatives to IVF, and she's here to tell us about it.

So Rachael, let's start with a definition. What is restorative reproductive medicine?

Robertson: So the bill defines it as "any scientific approach to reproductive medicine that seeks to cooperate with, or restore the normal physiology and anatomy of, the human reproductive system, without the use of methods that are inherently suppressive, circumventive, or destructive to natural human functions." It's a mouthful of a definition that's ultimately pretty vague and notably excludes IVF.

One of the methods touted by restorative reproductive medicine is called "natural procreative technology" or "NaProTechnology" -- which doesn't actually involve innovative technology or technique. I asked the American Society for Reproductive Medicine about NaProTechnology and restorative reproductive medicine more broadly, and a spokesperson there debunked these approaches pretty plainly. They said, "'restorative reproductive medicine' appears to be a political rather than a scientific concept," and that "ideologically driven groups have offered dressed-up versions of the rhythm method for many, many years; this appears to be the latest attempt." And indeed, the creator of NaProTechnology is the founder of a Catholic pro-life Medical Institute who had previously coined another similar fertility tracking method.

Fiore: So even if these methods aren't new science, how do they compare to IVF?

Robertson: I spoke with Rachel Weinerman, MD, who is a reproductive endocrinologist at Case Western Reserve University, and she told me that restorative reproductive medicine doesn't compare to IVF, but neither do other fertility treatments. That's because no other treatment optimizes every step of the process like IVF does. She called IVF the "most powerful tool we have" -- and that's because it offers the most control over the entire reproductive process.

Fiore: So how do fertility physicians even determine whether IVF is necessary?

Robertson: They first assess patients to see if there are any structural problems that might need surgical interventions, like blocked fallopian tubes or fibroids. And then there's also medications to increase sperm count or induce ovulation, as well as intrauterine insemination, where sperm is injected directly into the uterus. Often patients with unexplained infertility start with one of these non-IVF treatments. But if there's a non-hormonal reason that a man has no sperm, the only way he and his partner can conceive is by surgically extracting sperm and doing IVF with what's called ICSI, intracytoplasmic sperm injection, where a single healthy sperm is injected into a mature egg with a super thin needle. So in some cases like that, IVF is really the only option and there are no effective treatment alternatives. So that's why Weinerman said, ultimately, there is no true alternative to IVF, no matter what anyone else is saying.

Fiore: That sounds right. All right, great story. Thanks so much, Rachael.

Robertson: Thanks, Kristina. I'll take it from here.

As likely every medical student has heard, when it comes to differential diagnoses in clinical practice, when you hear hoof beats, don't expect to see a zebra! This phrase has become a well known adage for clinicians to remind them to focus on the most plausible diagnosis. But a shorthand of this phrase -- zebra stories -- has taken on a slightly different meaning over the years. Zebra stories are those fascinating cases when clinicians, or even a patient, go against those odds, trust a hunch and find that the right diagnosis is uncommon or unexpected. Michael DePeau-Wilson came across a recent Reddit thread where the poster asked people to share their favorite zebra stories, and the results did not disappoint. Because not all hoof beats come from horses.

Michael, can you tell us a little more about this thread and what kind of zebra stories you found?

Michael DePeau-Wilson: Of course, yeah. We came across this medicine subreddit thread last week where a person with the username Joseph_asked, "what [is] the most obscure but correct diagnosis you've seen suggested by a nonphysician?" And since that post, hundreds of people have commented on the thread, and dozens of them have shared their favorite zebra stories. And the results were, as one commenter put it, "like watching House in text."

Robertson: Okay, I'm dying to know which was your favorite story in the thread?

DePeau-Wilson: Oh, there were so many great stories, but I have to say, one of my favorite stories was by a commenter with the user name Notgonnadoxme who said that they were an EMT. And they shared a story about a 30-year-old guy with palpitations, elevated blood pressure and heart rate, who was very anxious. And they said their coworker assumed right away it must be triggered by some substance use. So they asked the man about taking stimulants, but the patient denied it.

Eventually, the patient seemed to remember that they did, in fact, smoke this white flower earlier, but they didn't remember what it was. And the commenter, on a hunch, asked if it was Jimsonweed, and the patient immediately said yes. And they said that their coworker was in disbelief for the rest of the night at this guess. And so the commenter apparently knew about this plant and its effects because they took a college course about plants that were historically used in religious ceremonies, and it just stuck in their brain. And so with that unexpected information, they gave the patient some midazolam for their symptom management and comfort before taking them to the ED without any issues. And later on, the commenter came back and put an addendum on their story and said that it just occurred to them that their story was an example of both non-medical education being useful and anthropology providing actionable information that could help impact patient care today. They said that was kind of a neat thing.

Robertson: I love that. And for the story, you also spoke with a bioethics expert, right?

DePeau-Wilson: Yeah, so I spoke with Dr. Joel Zivot, who is an associate professor of anesthesiology and surgery at Emory University and a senior fellow at the Emory Center for Ethics, and he told me that while he also loves a good zebra story, clinicians shouldn't be jumping at the chance to find one of these in their own practice. In fact, he told me that the problem with zebra stories is that zebras are more interesting than horses, but they are much less common. So these kinds of cases can be very rewarding, but as he put it, "the best diagnosticians are the ones who just play the odds." Still, he does think cases where a patient or provider suddenly finds a rare diagnosis for some unexplained condition aren't necessarily magic, either. He explained that those findings almost always come from a person's past experiences or even just a kernel of an idea from some past lecture in college or med school, kind of like the story I told you earlier. You know all of these zebra stories are rare, but clearly they're not impossible.

Robertson: And if you want to read more of the zebra stories, Michael's story has a few more examples. Thanks, Michael.

DePeau-Wilson: Thank you.

Robertson: And that's it for today. If you like what you heard, please leave us a review wherever you're listening now (, ) and hit subscribe if you haven't already. We'll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were 番茄社区 reporters Kristina Fiore, Rachael Robertson, and Michael DePeau-Wilson. Links to their stories are in the show notes.

MedPod Today is a production of 番茄社区. For more information about the show, check out medpagetoday.com/podcasts.

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