Molly Cooke in a recent article in the NEJM (Cooke, Molly Cost Consciousness in Patient Care -- What Is Medical Education's Responsibility? N Engl J Med 2010 0: NEJMp0911502) suggests that medical educators may have failed in their task of teaching medical students and house staff appropriate use of various diagnostic tests and therapeutic procedures.
While she acknowledges that there are various factors why physicians may order more tests or procedures, she states that medical educators need to do more to help change practice behavior of these future physicians.
Schools and residency programs already educate trainees on the concepts of Number Needed to Treat, Absolute and Relative Risk Reductions, Sensitivity, Specificity of Tests, Positive and Negative Predictive Values, Likelihood Ratios etc.
The New York Times in a recent article discusses whether the new health care reform act will lead to decrease in health care spending.
Do you think more training regarding cost conscious use of tests and procedures in medical school will lead to change in practice behavior of future physicians? Will other drivers like financial incentives overcome any effect of training? What do you think we can do as medical educators that will truly impact the cost of health care?
Neil Mehta
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5 comments:
No one in this world takes responsibility for anything. Costs are high for a million reasons. Many have to do with greed and others have to do with patient expectations that they can have anything they want
I remember when I was a resident (some 20 years ago), the pediatric ER I trained at had a framed sign that said "A Good History Is Worth 2 CT Scans". We are simultaneously blessed by the ready availability of high-tech diagnostic tools and increasingly dependent upon their information for clinical decision making. We have nurtured this culture of reliance on these tools in our students and residents in the belief that it is the best available care. But is it always necessary?
Health care resources are not infinite in supply. As we are pushed into socialization of the delivery and funding of services, we will be made ever more keenly aware of this. As educators, we are in a position to help influence this. It would be great to see some evidence-based infometrics on how to do this. If we had "Ottawa Rules" for many other areas of techology utilization, we could more prudently allocate and educate the next generation of physicians.
I believe medical educators need to be trained to diagnose medical problems more accurately and decrease wasted testing. If they listed more to the patient and asked more probative questions, fewer unnecessary tests would be ordered and costs would be contained.
Whether trained in correct use of procedures/tests or not, as long as our health care system is for-profit and incentive-based, physicians will do what benefits their bottom line. Cardiologists will do their caths, orthopedic surgeons will do their multi-level fusions, and anesthesiologists will do their spine injections.
Medical education fails to teach students how to practice cost effective medicine. I was trained that a diagnosis is 80% history 15% physical and 5% tests. That means 95% of your diagnostic work up could be "free".
Residents are insulated from the price of the services they provide(mostly becuase as providers, we are also ignorant).
Medical education needs to teach and empower students/residents on understanding billing/reimbursement. As long as the payor is separate from the doctor patient relationship, the patient and doctor are somewhat removed from the actual cost. Everyone needs more education in these areas.
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