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The Evolution of the Razor

November 24, 2019
by Mark David Siegel

Hi everyone,

Back in the day—maybe five years ago—we used to have monthly “Race Cases” at Report. The “Race,” as you might have guessed, was forerunner to the “Razor.”

The Race was just that- a race pitting the VA against YNHH, each side working furiously to be the first to solve a diagnostic challenge, usually a CPC from The New England Journal. The Chiefs would sync start times, maintain phone contact with one another, and declare a victor once one of the groups made the diagnosis.

The Race was fun and suspenseful. But the rules of the game also spawned warped behaviors, like wild, desperate guessing. You could win the Race by suggesting a random lucky diagnosis, even if you couldn’t explain your reasoning. It ultimately became clear that the Race incentivized intellectual shortcuts and sketchy reasoning, often devoid of higher thought.*

But wild guesswork didn't kill the Race; it died because I hated losing. As you all know, we have several master clinicians who regularly attend 9th floor Report. On all other days, it's a privilege to learn from them, but on Race Days, teaching ate up the clock, and we had to choose between teaching and winning. Since I wanted to win but didn’t want to silence the masters, we had to change the rules.

From this primordial stew, there emerged the Razor. In an era obsessed with cost consciousness, the theory was that we could transition from a contest that rewarded speed to one that rewarded clinical efficiency. The Chiefs would provide histories and physicals to the teams but withhold test results. Teams could ask for tests, but they would be charged for every test they ordered. To win, you had to make the right diagnosis while spending the least amount of money. As a side benefit, participants could talk as much as they wanted to. In turn, this gave birth to the Attending Razor, which at YNHH meant an opportunity to absorb the wisdom of our sages: Drs. Duffy, Kantor, and Kapadia.

In theory, the Razor reinforces a crucial habit, encouraging stewardship of scarce resources. To win, you need to be parsimonious. You need to forgo needless blood work, imaging, and biopsies. That’s the theory anyway, but like all efforts to control healthcare spending, the Razor creates its own perverse incentives and raises vexing questions: Does saving money always signify good medicine? If so, why don't we practice that way? Why do we routinely spend so much money on CTs, MRIs, and invasive testing? Can we reliably distinguish tests that are necessary from those are not?

The Razor’s incentive to save money spawns dubious strategies that can lead to your team’s downfall, like saving on a CBC that would have revealed severe thrombocytopenia, or forgoing a urinalysis that would have revealed severe proteinuria.

Wouldn’t it be better if we could incentivize teams to include a mandatory minimal workup while avoiding unnecessary testing? But what constitutes a mandatory minimal workup? Most of us could probably diagnose pneumonia by asking the right questions and listening through our stethoscopes, but would it be okay to forgo a chest x-ray? And while we can probably agree it would be excessive to get a chest CT on every patient with a COPD flare, can we reliably identify the subset presenting with PE?

Don’t get me wrong. For all its shortcomings, I love Razors. They’re fun to do and they encourage self-reflection and clinical reasoning. I particularly like our recent move to presenting our own cases; we have more than enough great material to present from Yale and the VA without having to lift cases from the literature.

But I wonder how we can make the Razors even better. For example, should we give teams the results of tests we know will always be done, like the CBC, routine chemistries, and U/A? Can we assume that everyone with shortness of breath will get a chest-ray, and that everyone with chest pain will get an EKG, and just give the results? And, if we want to promote best practice, should we let teams use online resources, like PubMed, GIDEON, UpToDate, and Google? Wouldn’t it be better to encourage a search for answers, rather than guessing, when we reach our limits?

I have no doubt that our clinical contests will continue to evolve, though I’m not sure how the rules should change. What do you think? What I do know is that nothing entices internists more than a true diagnostic dilemma, and nothing is more exciting than performing an elegant workup that leads to the right diagnosis. It’s there, at the razor’s edge, that we all feel like winners.

Enjoy your Sunday, everyone.

Mark

*Any perceived resemblance to modern medicine is purely coincidental.

Submitted by Mark David Siegel on November 24, 2019