Ranjana Srivastava

Speaking Up — When Doctors Navigate Medical Hierarchy

Awaiting surgery for a malignant pleural effusion, the man is in pain and looks much older than his 50 years. The medical oncologist thinks hes dying. But the surgeon believes the procedure will help, and medical hierarchy discourages questioning of such decisions.

What's the Alternative? The Worldwide Web of Integrative Medicine

A young woman wins a blood test at an integrative medicine seminar and is told she has circulating tumor cells, indicating advanced cancer, and requires a

A bridge to nowhere--the troubled trek of foreign medical graduates.

6,000 course of IV vitamin C. Petrified, she is difficult to dissuade. Whats a respectable oncologist to do?

On the Death of a Colleague

Dr. Ranjana Srivastava writes about her experience as a tutor to foreign-trained doctors taking a “bridging” course to earn medical credentials in Australia. These foreign doctors are driven by the dream of becoming doctors again, but the reality can be a nightmare.

Privacy and all that.

viders outside the ACO without patient or physician penalties. Some physician or patient preferences might well conflict with an ACO’s cost and quality goals. Such tensions may be irresolvable, but the organization could mitigate them by engaging physicians and patients in the process of choosing metrics for preferred providers, which could improve patient-centered care, ensure buy-in, and engender trust in the ACO. Engaging the wider provider community in the process could help ensure their buy-in, clarifying expectations and increasing their commitment to the goals of measuring and encouraging highvalue referrals. Finally, there’s the question of whether and how to incentivize physicians and patients to use and follow new referral practices. Influencing the process financially, by paying physicians bonuses or promising them a portion of the ACO’s shared savings, may be controversial and might rekindle the concerns about financial gatekeeping that plagued managed care. But financial incentives are not the only way to influence behavior.5 A more ethical approach might be to provide physicians and patients with data on specialists’ performance on the relevant metrics, perhaps in the form of a point-of-care decision aid, and allow them to jointly determine the best course of action; their mutual interest in choosing high-value care may be incentive enough for engaging in the desired referral practices. If information alone proves insufficient but physicians and patients retain control over referral decisions, additional incentives may be necessary to influence referrals. Nonfinancial incentives, such as organizational recognition of “high-value referrers,” may be a logical next step. If that approach is ineffective, carefully applied financial incentives, such as bonuses linked to high-value referral practices, may be necessary. For the use of such incentives to be ethical, however, patients must be informed of their existence, both by the ACO and by the referring physician.4 Whatever incentives are used, patients’ best interests should remain primary, and the incentives should not inappropriately influence medical decision making. If ACOs influence referral patterns in the right way, they could ensure the provision of high-value care. And influencing referrals by helping patients knowingly and intentionally choose the most appropriate physicians could actually be more respectful of patient choice and physicians’ duty of fidelity than current referral practices are. Whether the approach we envision is feasible in all circumstances remains to be seen, but we believe that ethical considerations should guide referral practices. Research is needed to elucidate ACOs’ current referral practices and their conformity to and effects on core ethical values. As health care organizations assume increasing financial risk, the need to influence referrals will probably grow, and today’s ACOs have an opportunity to develop and disseminate models for doing so ethically. No potential conflict of interest relevant to the article was reported. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

The Loneliness of Visiting

The two men had sat in neighboring chemotherapy chairs, swapping tales of side effects, antiemetics, their childhoods, religion. When one died, it affected the other profoundly. But theres no protocol for sharing information with patients about their fellow travelers.

No Refuge for the Ailing

How little must patients and their relatives really understand of our attempts to communicate with them. How many cues are missed on an average ward round? Could the way we talk make relatives feel uncomfortable instead of involved?

The Art of Letting Go

In this essay, Dr. Ranjana Srivastava, a volunteer at a refugee clinic, describes caring for a patient who was denied refugee status, and thus, access to health care. Dr. Srivastava asks where, really, does our duty as physicians lie?