By Allan Joseph
Pretty much every conversation I’ve ever had about working to change physician culture boils down to two words: “medical education.” That was especially true at the 2013 Lown Institute Conference, which focused on the issue of right care: eliminating harmful overuse and harmful underuse. This comes down to reforming the way today’s physicians practice — eliminating the ordering of expensive tests and treatments that provide little to no benefit to a patient and often cause a patient harm.
What struck me about all the medical-education discussion was that it focused on training fellows and residents. If anyone in the medical field talked about training medical students in cost-conscious care, it was third- and fourth-year students. Although, this isn’t a bad thing, it is relatively concerning. After all, those are the trainees who are in the hospital and have the most direct path to watching cost-conscious care in action. However, it also highlights a huge problem: it requires convincing a critical mass of attending physicians to teach the trainees the necessary care as those trainees work with and learn from many different physicians. That’s a really tough battle to fight, and it takes a long time to convince highly trained physicians to change their ways.
Yet there’s an opportunity to sidestep that challenge — start earlier. Start with the physicians and professors who lecture pre-clinical students. Rather than working with a whole department of, say, cardiologists during their clinical rotations, pre-clinical students have just a few lecturers shaping their initial exposure to cardiology. That means getting just two or three physicians to integrate cost-consciousness into their teaching can shape the way an entire class of trainees thinks. This is a high leverage activity that will change the students’ perspective on cost very early on.
I’ll give you an example from my own (admittedly short) career as a medical student. Our genetics block was taught by four lecturers: two physician-geneticists, and two genetic counselors. After a quick introduction to the principles of genetics, our block focused on specific important to clinical practice: understanding a family genetic history to draw out genetic information, estimating risks based on that information, and understanding what tests were available to diagnose certain diseases. Rather than simply providing us lists of tests, however, our lecturers pushed us — including on our examination — to understand when to order which test. For example, though cystic fibrosis (CF) can be diagnosed via whole-genome sequencing, ordering an allele-specific oligonucleotide (ASO) panel can detect anywhere from 49 to 94 percent of CF cases depending on the patient’s ethnicity — and it’s cheaper. Therefore, the answer to the question of which test to order in a baby exhibiting symptoms of CF was not Sanger sequencing, though that test will detect essentially all cases. The answer was to first order an ASO panel, then to run Sanger sequencing if that panel was negative.
Quite frankly, that changed the way I thought about genetic testing, and diagnostic testing in general. Rather than simply ordering the expensive “gold standard” test, it’s possible to order a cheaper, quicker test that will work in most cases — and then, if needed, step up to the comprehensive test. In fact, that’s now how my classmates see testing. It didn’t require a sea change in the pediatric hospital’s Division of Genetics (though that would help reinforce the lesson in our clinical rotations), but rather simply the efforts of a few lecturers. Also, as an added bonus, our very first exposure to genetic testing was taught with thoughtful decision-making in mind. When we finally hit the wards, we will draw on this knowledge and have the opportunity to put it into practice for our patients.
We should continue to teach fellows, residents, and other trainees how to practice thoughtfully, with costs in mind. We should continue to work at convincing each and every attending physician to do the same, despite how they may have been trained in their past. If we want to start making a change in the physicians of the future, we need to teach students this lesson on high value care from the very beginning because if you’re trained correctly from the outset, you won’t know any other way to practice.