Is More Medical Testing Better?

“I think this patient needs a CT scan of her chest,” the consulting
physician said to me over the phone. “Her lungs sound bad, and given her
history, we need to make sure she isn’t developing pneumonia.”

The patient, though only thirty-five, had been through a lot during her
hospitalization. She came in a week prior with some shortness of breath, an
abnormally high heart rate (tachycardia) and chest pain. But her heart
checked out just fine. An EKG was normal and her troponin, a protein
that spills into the blood with damage to heart, was undetectable. Because
of her tachycardia and chest pain we tested her for a

pulmonary embolus
, or clot in the lungs, with a CT scan. It was positive. The potentially
deadly clot blocks off blood flow coming from the right side of the heart
into the lungs causing heart strain and disrupting oxygenation of blood and
the functioning of the heart.

We admitted the patient to the

intensive care unit

where she received IV medication to thin her blood. She recovered but
continued to experience residual chest pain that would clear in the months
ahead. As we prepared to discharge the patient, the consulting physician, a
cardiologist, told us he wanted her to get another CT scan of her chest.
She had not had a scan since the initial stages of her workup. What if she
developed pneumonia in the interim? Her white blood cell count, often a
crude marker of infection, was not elevated. She did not have fevers. When
asked, she felt well enough to go home and wanted to leave. Then again,
being in the hospital made her susceptible to infection. Moreover, on her
physical exam, we heard crackles in her lungs –
this sometimes indicates an intrapulmonary pathology. The cardiologist’s
concern gave us pause and we ordered the imaging study.

~

Doctors often feel uncomfortable with areas outside of our expertise. Consequently, we call other specialists to see the patient and give us advice. Moreover,
patients sometimes ask to see a specialist in the hospital: “Can you call
the neurologist to come see me?” or “We’d like you to call a cardiologist
to see our father while he’s here.” Because consultants share a different
knowledge base than the team primarily caring for the patient they may ask
for more tests to rule out other serious pathologies that the primary team
neglected to consider.

The patient’s repeat CT scan merely demonstrated small collapsed alveoli.
These terminal branches of the lungs often collapse when we draw shallow
breaths or lie flat for a long time, a typical finding in many hospitalized
patients. Given the benign nature of this finding, we discharged the
patient. Yet she had received an extraneous dose of radiation and her
hospital bill would be hundreds of dollars more. Did she absolutely need
this? This common story raises other questions, too. Do patients do better
with more specialists seeing them? Do patients do better with more testing?

In a 2012 post for the New York Times Well blog, Tara Parker-Pope

pointed out

that “overtreatment – too many scans, too many blood tests, too many
procedures – is costing the nation’s healthcare system at least $210
billion a year, according to the Institute of Medicine.” And the stories
she tells about astronomical hospital bills due to overtesting are
disturbing.

In
a 2015 article in the Journal of the American Medical Association, a group of researchers found mortality for high-risk
heart failure and cardiac arrest among patients was lower in teaching hospitals
during national cardiology meetings compared to the rest of the year – meaning that the absence of a large number of cardiologists, who were attending meetings, was correlated with lower mortality for these heart conditions in the hospital. In an editorial in the same issue, Dr.
Rita Redberg makes a disquieting suggestion: “How should we interpret these findings? One possibility is that more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” Is there too much being done, especially by experienced
physicians?

Dr. Ezekiel Emanuel, an oncologist and bioethicist, elaborated on these questions in a New York Times op-ed in 2015:

We – both physicians and patients – usually think more treatment means
better treatment. We often forget that every test and treatment can go
wrong, produce side effects or lead to additional interventions that
themselves can go wrong. We have learned this lesson with treatments like
antibiotics for simple medical problems from sore throats to ear
infections. Despite often repeating the mantra “First, do no harm,” doctors
have difficulty with doing less – even nothing. We find it hard to refrain
from trying another drug, blood test, imaging study or surgery.

When specialists like neurologists or cardiologists see a patient, they
approach the bedside from a unique perspective. The pathologies they know
and think about are very different from what family medicine or internal medicine doctors thinks of when they see a patient. Specialists, who often act as consultants, consider the diseases they are most worried about within their field. They’ve been asked to see the patient to
recommend workup for a disease potentially related to
their area of expertise. Their view, in other words, is necessarily myopic – if you give a carpenter a hammer, surely the carpenter will find a nail.
This does not always happen, but by nature there is a bias when a consultant
approaches a patient – and that bias is toward ordering another test,
toward doing something. Part of the art of medicine, especially as a specialist or consultant, is figuring out when the patient needs
something and when the best approach is to do nothing at all. Our patient
at the beginning of the story did not really need a repeat CT scan. To be
sure, the cardiologist didn’t recommend it simply to radiate the patient or
increase the hospital bill. But none of us wanted to miss something.

A conservative method of practice can come with experience, but as evident
from the JAMA study referenced above, that’s not necessarily the
whole story. Some of this, I think, requires thinking regularly about how well the
patient in front of the doctor is doing and how a test will change the
course of the patient’s treatment. “Will this change our management?” is a
question our attending physicians always ask us before we order a test. And it is a
question all doctors must ask themselves.

The Case for “Pimping” in Medical Education

Illustration by William Sharp (National Library of Medicine)

“What are some common causes of

pancreatitis
?”

The attending physician looked at me as we stood outside of the patient’s
room. It was as if she had turned a stage light on over my head while
medical students and residents silently waited at my flanks, watching with
bated breath. I stammered and said, “alcohol.” 

“And what else?”

This time the question was directed at another medical
student. I breathed a sigh of relief. It was my first time experiencing
what everyone in the medical field calls “pimping.”

***

On

rounds
 in the hospital, attending physicians “pimp” — that is, publicly interrogate —
medical students and residents about various aspects of disease and disease
treatment. Physicians have practiced this method of teaching and testing
for years.

Dr. Frederick Brancati popularized the term in “The Art of Pimping,” a 1989 article for the Journal of the American Medical Association that satirized the practice. He humorously (and seemingly apocryphally) tells us how the word was first used in the seventeenth century by

Dr. William Harvey
, the physician who discovered the circulatory system. Harvey allegedly
said of his students:

They know nothing of Natural Philosophy, these
pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O
that I might see them pimped!

Brancati continues with his satirical history by relating how William Osler,
the father of modern medicine, used the method and its moniker in the
United States. Abraham Flexner, an educational reformer and eponymous author of the

Flexner Report
, which detailed the failure of American medical schools to teach science
properly, supposedly described Osler’s method in his diary:

Rounded with Osler today.
Riddles house officers with questions. Like a Gatling gun. Welch says
students call it ‘pimping.’ Delightful.

(For what it’s worth, neither the Oxford English Dictionary nor Merriam-Webster list this usage of the word. But one irked respondent to Brancati’s article offered an alternate etymology, arguing that pimping is actually a malapropism of pumping, meaning “to question persistently.” The writer insisted on correcting the record, “Lest this word, possibly used as a sensational catchword, become a neologism.”)

***

Pimping, though used often in the hospital, does not comprise the bulk of
medical education. Prior to the third year of medical school, a student’s
knowledge is tested with a plethora of multiple-choice exams. Some of these
are higher-stakes than others. For example, one must pass Step 1, the first of three exams
comprising the medical licensing process, in order to apply for residency,
and one’s score determines where one trains.

It might seem, then, that pimping takes a back seat to such exams. But in
reality they complement and build on each other. Given that Step 1 is a
multiple-choice test, if you can recognize the answer then you can get the
question right — you don’t have to be able to recall it from memory.

But
pimping takes medical education to a different level. Not only does one
have to recall the precise answer from memory when being pimped, but one has
to do so in a kind of theater, in front of the whole medical team and,
occasionally, the patient.

To answer these unpredictable questions correctly, one must know a great deal and
demonstrate that knowledge under great stress. This is very
difficult indeed. The cellular and sub-cellular aspects of human biology are
dizzyingly complex. Proteins, hormones, cell membranes, hemoglobin, acids,
bases, and many more players all interact with each other in different ways.
The biochemical and cellular processes merge together into systems like the
cardiovascular and nervous systems. One could study these systems
for years and still not be comfortable with them. And they all affect each other. The kidney can compensate for a respiratory issue. The
respiratory system can change because of a musculoskeletal issue. One has
to understand these interactions to treat disease. Consequently, a medical
education must be broad and deep.

***

How does one memorize or even recognize all of this information? One method
involves creating mnemonics or poems. This is a perennial trick used not
just by medical trainees but by religious groups as well.

In an
article for Aleph, Maud Kozodoy explores this technique within the medieval Jewish tradition. Medieval Jewish scholars used poetry to memorize religious and medical
facts. As Kozodoy writes, “versification facilitates memorization.”
Moreover, “verse preserves the integrity of a given text or, putting the
point negatively, reduces the possibility of its corruption.” Galen, the famous Greek
physician of the second century AD, recognized
this:

drug prescriptions in verse form are more useful than those written
in prose with a view not only to memory, but also to the accuracy of the
proportion in the mixture of ingredients.

Kozodoy offers another example, translating from the Hebrew a verse by Yannai, an Israelite poet circa the sixth century AD, “based on the rabbinic dictum that the 248 limbs/organs of the body correspond to the 248 positive commandments given at Mount Sinai”:

Then, two hundred and forty-eight limbs / You fashioned in man and attached
to him. // You chose thirty for the soles of [his] feet / accustoming them
for good and for evil. // You decreed ten for [his] feet / so that they
would not slip…in the receiving of the ten commandments.

Modern medical education draws from this rich tradition of versification.
Though we don’t typically memorize poems in medical school or residency, we do come
up with short phrases that allow us to retain important information. Take,
for example, the side effects of an anticholinergic
medication like diphenhydramine (Benadryl), which blocks acetylcholine receptors in the nervous system. Most students
and physicians memorize the overdose effects using the following short
mnemonic:


Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a
hatter.

When you overdose on anticholinergic medications your body temperature
increases, your pupils dilate, your skin dries up and flushes, and you can
become delirious. We try, whenever possible, to find mnemonics like these when studying for exams, as they often make memorization easier.

***

Another method that helps us memorize information, though it sometimes
goes unrecognized by its victims, is being the target of pimping. This makes pimping both a
way to test knowledge — as in the story that opened this post — and a way to accumulate
knowledge.

An attending physician once pimped me about the treatment for a

pulmonary embolism
, a clot that has migrated to the lungs and cut off blood supply, leading to
rapid deterioration and death. One of my answers was to use

nitroglycerin
, a drug that causes vasodilation.

But I was very much wrong. The attending
immediately said to me in front of the whole team, “you’ve just killed your
patient.” Because nitroglycerin dilates vessels, it decreases the pressure
of blood being pushed into the heart, and consequently decreases the force
with which the blood is pushing into the pulmonary circulation and
bypassing the embolism. If you do this, the body can no longer push blood
past the clot, and you can die.

I will now never forget this fact. It
was a stark reminder of how much more I had to learn, especially given how
terrifying the consequences of my treatment would have been had I used it
on a real patient.

Pimping is equal in potency to poetry and
mnemonics in searing facts into one’s memory.

***

Recently, there has been some controversy over pimping as an educational
method. Dr. Dhruv Khullar, a physician at NewYork–Presbyterian Hospital,
wrote in a post for the New York Times’s Well blog that this style of teaching, in which we are only expected to demonstrate how
many facts we know, “encourages us to learn to show, not grow — to project
confidence, and dismiss uncertainty.” Suzanne Gordon, a
medical journalist, wrote in

a blog post for
 the British Medical Journal that pimping discourages health care providers from admitting mistakes:

If a fundamental
communications skill learned in medical training is to confidently
communicate knowledge that one does not actually possess, never express
doubt, and avoid at all cost embarrassing a medical superior then patient
safety truly becomes a mission impossible.

But this seems to miss the point. Pimping, if not done
maliciously, is an effective exercise in testing and teaching. After four years of medical school and two years of residency, I still get pimped and there
is still much that I do not know. Every question directed toward
a student or resident is also a lesson in humility, about how much there is
to learn.

What we need instead, as Dr. Khullar argues, is a shift in attitude about what it means to get
something wrong.

As part of the learning process in medical school, students should be
encouraged to fail, and to learn from those failures so that they better
succeed as physicians. As a 2012 study in the Journal of Experimental Psychology: General demonstrated, children actually perform better in school if they are told
that failure is a normal part of the learning process. They have a better
working memory and are more effective in solving difficult problems.

Failure also teaches us to adapt because we remember what to do when the
same situation arises again. When I face a real patient with a pulmonary
embolism, I am certain I will not give that patient nitroglycerin.

There is a relatively small and brief price to pay for getting a question wrong while
being pimped. But the stakes are far higher when you are the one making the
decision about a real human being. And to learn from such failures as a
medical student is in the best interests of both the budding physician and of his or her future patient.

Editor’s Note: This post has been updated to clarify that the poem by Yannai was not specifically written for use in medical education.