Can We Teach Physicians to Consider Cost?

My best friend’s daughter is pre-med in college. She’s brilliant, and is planning to become a developmental pediatrician (as of now, at least). By the time she enters medical school in two years, I really hope she learns not only anatomy and physiology, diagnosis, and how to insert a breathing tube, but how to consider the cost of the care she provides.

Residents have been required to learn how “incorporate considerations of cost awareness and risk-benefit analysis” in caring for patients since 2007, but how this is done is unclear. In addition, few medical schools provide any such training. Indeed, talking about cost in medical training has traditionally been tantamount to giving voice to “he-who-must-not-be-named.”

That is changing, as it must in a healthcare system that now makes up 18 percent of GDP, with costs typically rising far faster than inflation. As Molly Cooke, MD, wrote in a 2010 editorial in the New England Journal of Medicine, “We must be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit.”All physicians, including those in training, she wrote, must learn to use “cost-conscious strategies” in caring for patients.

This is beginning to occur. For one, major medical societies like the American Society of Clinical Oncology, the American College of Cardiology, and the American Heart Association are incorporating cost-effectiveness information into their guidelines (more on this in a future blog). That will require  clinicians in those areas to consider the value of tests and treatments in patient care, value being defined as cost+quality/outcomes. In addition, the American College of Physicians has called for “high-value, cost-conscious care” to become a critical competency for physicians.

Yet, as The New York Timesreported in 2010, only about 60 percent of US and Canadian medical schools include material on health care costs, with wide variation to the time devoted to it. More recently, a survey of 300 internal medicine residency programs found that less than 15 percent have any formal curriculum addressing healthcare costs. Even more frightening is that the study found that just half said the majority of their faculty “modeled cost-conscious care,” and just a third said that their residents even had access to cost information for the tests and procedures provided.

Hopefully, this is changing. At the University of Michigan’s Medical School, for instance, all first- and second-year students must take courses in health policy and economics. And in that survey of residency programs mentioned above, half said they were “working on one.”

They better get moving. My friend’s daughter will be starting her residency in six years.





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