05 Aug High-Value Medical Decision Making Starts in the Classroom

By Brian Powers

Edward arrived at the hospital following a stroke; a standard work-up failed to reveal an obvious cause. His physician explained that a previously diagnosed patent foramen ovale (PFO), a hole in between the chambers of his heart, may have led to his stroke. He presented three possible treatment options to Edward: (1) medical management with drugs; (2) open surgery to correct the defect; or (3) interventional catheterization to correct the defect.

Edward and his physician face a difficult decision—recent studies have not shown any of the three approaches to be definitively superior in preventing future strokes. Medical management would not correct the defect, but would reduce the chance of a future stroke-causing blood clot. Interventional catheterization or surgery would close the hole, but both, especially surgery, pose more serious risks and a longer recovery times. Edward and his physician must also consider the cost of each intervention. What out-of-pocket costs would Edward face for the more expensive interventional options compared to long-term co-payments for prescriptions? Moreover, what are the system-wide implications of choosing a high-cost intervention without evidence for superior effectiveness?

Thousands of physicians and patients confront these decisions every day. The clinical context varies, but the goal is always the same: to choose a high-value treatment that meets the patient’s goals. To do this, physicians must be able to elicit patient input as well as understand the clinical benefits, side effects, and costs of each treatment option.

But anyone who has participated in a medical decision—patient, provider, or family member—understands that this does not always occur. For example, clinical evidence may not be adequate for the decision at hand, or communication barriers may hinder patient and family participation. Information on costs, especially out-of-pocket costs, is often either inaccurate or hard to find. Furthermore, discussing cost and value still is not a routine aspect of the clinical decision-making process for many physicians. We have made progress on many of the challenges, but our ability to provide value-based care is still a struggle.

So how do we create a more cost-conscious environment for medical decisions? To start, we must help physicians develop the competencies necessary to incorporate considerations of cost and value into the decision-making process. This is especially true for early trainees. Building a foundation of cost-related knowledge and tools in medical school allows students to approach their clinical training with an understanding of, and a focus on, high-value treatment decisions.

Unfortunately, medical students today receive very little instruction on these important topics. This is not due to a lack of support, but rather to the challenge of implementation. A 2011 survey found that while leadership at most medical schools favors a stronger focus on cost and value, there is not enough curricular flexibility to incorporate these topics into undergraduate medical education. Within an already compressed schedule, any attempt to improve education on cost and value detracts other important topics. Successfully incorporating cost and value into pre-clinical medical education requires integrating these concepts within existing curricular components rather than developing additional classes and modules.

Leveraging cases like Edward’s is an important opportunity for integration. Over the past two decades, case-based modes of learning have become commonplace at most medical schools. One example is problem-based learning (PBL), where students learn by working through real clinical cases in small groups. At many schools, students spend about as much time in PBL sessions as they do in traditional lectures. For Edward’s case, students would be prompted to research existing guidelines and literature for treating strokes in patients with PFOs, and to then consider which treatment to recommend. These PBL cases easily could be amended to include a focus on cost and value. In addition to the clinical components, students could be asked to research the cost of each treatment, decide if this would change their recommendation, and contemplate how they would discuss cost and value with the patient. Since these types of cases are already a core component of most curricula, medical schools can increase the focus on cost and value without diverting attention from other important topics.

PBL and other case-based approaches have become popular because our professors believe it helps model and develop our skills in clinical decision-making—processes that we are expected to emulate on the wards and in practice. Incorporating cost and value into PBL cases is an unrealized opportunity to prepare future physicians for high-value decision-making. If medical students can learn from Edward in the classroom, they will be poised to provide high-value care when they see similar patients on the wards.


Brian Powers is an M.D. candidate at Harvard Medical School. Previously, he worked at the Institute of Medicine’s Roundtable on Value & Science-Driven Health Care.  He is also previous contributor to the Costs of Care Blog.

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