The Lown Institute Vignette Competition challenges medical students and trainees to shine a light on everyday overuse and underuse – common practices that either give patients unnecessary tests and procedures, or that fail to give patients necessary care. Sharing stories of the downstream consequences of overuse can be a powerful counterbalance to the ‘more is better’ culture and can help clinicians recognize and avoid overuse. Learn more about the competition and read all the vignettes here.
This week, we have an interview with Dr. Neil Keshvani, a third-year internal medicine resident at the University of Texas Southwestern Medical Center. Keshvani, along with colleagues Dr. Ank Nijhawan and Dr. Arjun Gupta, were recognized as finalists in the Lown Vignette Competition.
Lown Institute: Tell me about the case.
Dr. Neil Keshvani: We had a walk-in patient at our clinic who complained of painful urination and urethral discharge. This was my first time seeing the patient, but I saw from his chart that he had come to the clinic three weeks before with the same symptoms, and had been treated for gonorrhea.
I was worried that he might have an antibiotic-resistant infection, but when I talked about the case with Dr. Gupta, he said, “We have to focus on the partner.” It turns out it wasn’t antibiotic resistance, but that his partner hadn’t been treated for the infection, and he got reinfected.
Like many people, this patient was embarrassed to tell his partner about the STI (sexually transmitted infection), so he didn’t tell her to get treatment. But the happy ending is that we treated both partners and they had no symptoms at their follow-up visit three months later.
What did you take away from this case?
When we treat a patient with an STI, we are really treating two or more people – the patient and their partner(s). That’s something doctors aren’t used to doing, but has become more of our responsibility as local health departments are overburdened and don’t have time to track these infections. Only 20% of people get notified about an STI through the health department, so it’s really up to the health provider to assist in this.
Another takeaway is that there are easier ways to engage partners in medical treatment for STIs if they aren’t comfortable coming into the clinic. Expedited partner therapy (EPT) allows a health care provider to give the patient a prescription for an STI and an extra dose to give to their partner, along with more information and barrier protection.
Why is it so difficult to engage partners as well as patients in treatment and prevention?
One of the big problems is that it’s awkward to ask about sexual history. Patients often don’t want to have these conversations with people. We learn that you have to dig deep and ask these questions, because getting a good history is most important thing for a primary provider.
Also, patients are often uncomfortable talking about STIs with their partners. But there are resources out there that allow for patients to notify their partners anonymously, and encourage them to get testing and treatment.
What makes this case different from other Lown Vignettes or Teachable Moment stories you’ve seen?
There’s been a big push at our institution to locate and root out low-value care, like minimizing unnecessary disagnostic testing and antibiotic use. But there’s an important corollary, which is we should be trying to also do more high-value care. This can be even harder than reducing low-value care.
This case doesn’t focus on eliminating waste. Instead, it focuses on expanding high-value care. It shows that less is more, but only in certain cases!