20 Oct Training on Cost Decisions at the Bedside
By Nandita Mani and Elizabeth Oler
Medical students are brilliantly frugal. And it’s no surprise — according to the AAMC, the average U.S. medical student incurs $170,000 of debt from medical education. We are a resourceful, smart, and cost-conscious group — so why is the medical school curriculum practically silent on the cost of medicine?
During medical school, we are taught to be excellent diagnosticians. The third and fourth years of training provide 60 to 80 hours a week of hands-on learning in the hospital and clinic. We diligently elicit patient histories, perform physical exams and record daily medications, lab results, and pain levels. We are encouraged to manage our patients independently, to think critically about their medical and surgical problems, and to practice evidence-based medicine by integrating the newest research into our plan of care.
However, a critical piece of our education is missing: we do not address the cost of medicine in any systematic way during our time in lectures or on the wards. Discussions about finance at medical schools across the country are sporadic at best.
No matter how strong our clinical skills, we cannot be great physicians if we do not understand how much we spend. The role of a doctor is not just to make the right diagnosis; it is also to promote sustainable health care for our patients and society. Responsible medical practice must consider what that care costs, and the health of our economy depends on it. According to the Institute of Medicine, the cost of health care has ballooned so much since 1945 that if the price of milk had kept apace, we would be paying $48 per gallon. Despite this trend, our medical education is markedly shielded from the financial structure of medicine, both in the pre-clinical and clinical years.
A study published in JAMA in April showed that physicians at Johns Hopkins Hospital ordered 10 percent fewer laboratorytests when prices were displayed at the time of order entry — information that most hospitals do not offer. Before clicking “submit,” physicians were forced to think, ‘Is that comprehensive metabolic panel really worth $15.44?’ If the results were vital to patient management, then the answer should have been yes. But if a basic metabolic panel — similar, but without liver function tests — sufficed, it cost $3.08 less. This small amount added up, with the hospital saving more than $27,000 over six months. Without “rationing” medical care, and while still obtaining the necessary clinical information, doctors were able to reduce costs significantly.
At the point of care, when it comes time to make a clinical decision, physicians have tremendous power to influence health care spending. In an ideal world, clinical decisions could be made without consideration to cost. But in a system where resources are increasingly limited and health care costs are prohibitive even for the wealthiest Americans, we cannot escape this essential component of our future practice. Conversations about cost value need to be had both in the classroom and on the wards. What if students were pushed to defend the cost benefit of their treatment plans during morning rounds? This would open the door to constructive discussion about sustainable and affordable care that still reaches the best possible outcomes for our patients.
We believe that teaching medical students to become doctors without exposing them to the realities of cost is akin to practicing medicine in the dark. We have taken the Hippocratic Oath, and if we are truly to do no harm, we must openly discuss the financial burden placed on our patients and society before making important clinical decisions. The gargantuan task of making medicine affordable must be a multidisciplinary effort in which physicians play a defining role — and medical students must be trained to fill that role.
The culture of medicine is changing, and medical education must not only adapt, but also lead the charge in shaping this shift.Cost-conscious young people are perfectly situated to take on the challenge of reducing the cost of health care at the bedside. If asked to critically examine the price of what we do during our training, we may be able to bend the cost curve of health care in the right direction.
Nandita Mani and Elizabeth Oler were contestants in the 2013 Costs of Care Essay Contest.