Medical education’s efforts to incorporate the teaching of value-based care into formalized curricula have been remarkably few and fraught with challenges. More than 60 percent of med school grads feel they get inadequate instruction in medical economics, a figure that hasn’t budged in more than five years. At the same time, residents are subjected to the insidious influence of a “hidden curriculum” that seems to shun conservation in favor of consumption. The result is predictable: We are churning out providers who feel neither prepared nor compelled to allocate clinical resources more sustainably.
It’s not uncommon for trainees to contemplate the cost of a test or treatment. But that thought rarely ends up being more than a fleeting curiosity. While juggling an exponentially increasing body of data and evidence, consensus-based guidelines, attending preferences, and the increasing complexity of patients, adding another variable to our calculus seems daunting.
The common refrain is, “We don’t have enough information to make value-based judgments.” Discussion of cost-effectiveness among trainees usually centers on price transparency—or rather, a lack thereof. Survey the workroom of an academic hospital and you’ll get five different estimates for the cost of a CT scan. The monumental price tag of some items is even the source of folklore among residents: “Did you know that stress test costs $5,000?!” Adding to the myth’s power is the fact that, prior to the recent decision by Health and Human Services to release hospital chargemasters, those documents have been treated like trade secrets. Even if an enterprising resident were able to obtain the classified dossier, the listed charge would bear no relation to the price the patient eventually pays.
But clinical malaise and the abstruse nature of hospital pricing should not prevent us from grappling with the excess and overuse typical of most training environments. As tertiary referral centers, teaching hospitals attract a subset of patients seeking an exhaustive workup or more aggressive care from thought leaders (our mentors) in subspecialty fields. Accordingly, these mentors are more likely to ask, “Why didn’t you order test X?” ratber than, “Why did you order test X, and what are you going to do with the information?” . A superfluous test is a “good thought.” A step-wise evaluation is often “expedited” with a single round of testing. An outside workup is repeated to have “all the data in-house.” These behaviors are then reinforced by our conferences, which focus on extensive diagnostic evaluations of rare diseases.
At its core, this is an issue of culture and our unbridled pursuit of clinical excellence. Trainees can and should help refashion this culture to achieve better value for patients. Student activism has heavily influenced the practices of today’s medical schools and residency programs, perhaps best evidenced by the American Medical Student Association’s PharmFree Campaign. The success of the Institute for Healthcare Improvement in spreading the principles of quality improvement (QI) can be attributed in part to the enthusiasm of trainees, empowered by the Open School to create and champion their own curricula. At a microsystem level, residents might incorporate value into QI projects and institutional research, or lobby at an administrative level for increased information about the costs of their practice. As individuals, we can leverage our greater familiarity with new media and technology to promote resources such as Choosing Wisely, Healthcare Bluebook, and Consumer Reports Best Buy Drugs.
There are promising signs that current physicians-in-training are committed to championing the principles of resource stewardship. Costs of Care, a 501c3 non-profit social venture founded by trainees, has used crowdsourcing to engage both patients and physicians in the discussion of value-based care. More than 300 real patient and physician stories illustrating opportunities to provide high-value care have been generated by their widely publicized annual essay contest. More formalized curricula in cost awareness at UCSF and UPenn originated from the work of residents. As a medical student, I was fortunate to be a part of a team that created a web-based curriculum in overuse.
There are undoubtedly other examples of “conservationists” in training out there. We want to meet you! We will be presenting our work at the upcoming AAMC IQ conference on June 6. Come to Chicago and tell us about your project, whether it’s a completed program or just a fresh idea. Or you can find us online at http://teachingvalue.org/competition.
— Andy Levy, MD, is a resident in internal medicine at the University of Chicago. He can be reached at email@example.com.