Residency Training Should Stress Cost-Conscious Care

September 20, 2011

September 20, 2011 — "Why didn't you order test X?"

That question, posed routinely to residents by faculty members at teaching hospitals, bears some of the blame for the high and unsustainable cost of US healthcare, writes a leader of the American College of Physicians in the September 20 issue of the Annals of Internal Medicine. In other words, residents develop a "more care is better care" mindset, with little thought to cost-effectiveness.

American College of Physicians Chief Executive Officer Steven Weinberger, MD, contends in an opinion piece that residents ought to be hearing another question as well — "Why did you order test X, and what are you going to do with the information?" — as they learn about the economic implications of their care.

The need for physicians to avoid unnecessary tests and treatments, writes Dr. Weinberger, is so important that cost-consciousness and stewardship of medical resources ought to become a new general competency for residency programs. It would join 6 other competencies formulated by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.

The 6 existing competencies center on medical knowledge, patient care, professionalism, interpersonal and communication skills, practice-based learning and improvement, and system-based practice, which stresses knowing how to work with others within the larger healthcare system. The subpoints for this last competency include an expectation "to incorporate considerations of cost-awareness and risk-benefit analysis...as appropriate," but Dr. Weinberger writes that embedding the cost issue in this competency is insufficient.

Instead, he proposes a seventh competency that reads as follows: "Understand the need for stewardship of resources and practice cost-conscious care, including avoiding the overuse and misuse of diagnostic tests and therapies that do not benefit patient care but add to health care costs."

Wasteful Habits Hard to Break

Roughly 30% of healthcare costs are wasteful and avoidable, and eliminating the services behind them would not harm patients, Dr. Weinberger writes, citing published estimates of the problem. Dollars are squandered by more than just piecemeal tests and procedures. Physicians also must recognize opportunities to prevent a hospitalization or readmission, he writes.

Inculcating an economical mindset needs to start early, according to Dr. Weinberger, because "habits that are developed during medical school, residency, and fellowship training often persist throughout a career." They are hard to break for established practitioners, who receive fewer opportunities to be influenced by respected role models.

Frugal medical habits hold more promise for controlling costs than laws and regulations coming from Washington, DC, according to Dr. Weinberger.

"Attempts to solve the problem by legislating reductions in Medicare and Medicaid spending are not addressing the real problem because they are focused on reducing reimbursement for care, not decreasing the actual cost of care," he writes.

Dr. Weinberger has disclosed no relevant financial relationships.

Ann Intern Med. 2011;155:386-388. Abstract

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