Counting the Cost
Edition: March 2012 - Vol 20 Number 03
Recently, MDSI, publisher of Repertoire, submitted several questions to Weinberger. Here are those questions, and Weinberger’s responses.
MDSI: Why did you choose the year 2011 to suggest a general competency in cost-conscious care and stewardship of resources? What would have happened had you suggested this, say, 10 years ago? Five years ago?
Steven Weinberger: This time is particularly critical, given the federal debt problem that is driven in large part by the ever-escalating costs of healthcare. Suggesting this five or 10 years ago probably would have gotten some interest, but nowhere near the type of interest and traction that it is getting now.
MDSI: Why do you say in the Annals article that past efforts to teach residents about cost-effective care have not been particularly effective? What have been the shortcomings, and how can they be overcome?
Weinberger: Past studies that have looked at the issue have shown transient rather than long-lasting benefit. I think the main problem is that there needs to be a real change in the culture of the training environment, much of which needs to be driven by the faculty. The faculty are important not only because of what they teach and what they stress to trainees, but also because of the role model they set in their own care of patients.
MDSI: In the Annals article, you make the point that the question most often posed on teaching rounds is, “Why didn’t you order test X?” rather than “Why did you order test X and what are you going to do with the information?” How do you “train the trainers” to teach cost-conscious care and stewardship of resources? How quickly can this change of culture in today’s medical schools be implemented?
Weinberger: I think that the early trainers will need to learn alongside the trainees. We’ll need some educational materials and standards to come out nationally (e.g., from the American College of Physicians and other organizations), supported, hopefully, by a few “champions” at each institution who want to effect change. I suspect this type of change will take a couple of years.
MDSI: What would this training look like?
Weinberger: The training is partly didactic – probably done through case-based studies – and is partly in the course of patient care, through the types of discussions and teaching that go on every day in teaching institutions as part of routine patient care.
MDSI: In Annals, you write, “Residents must recognize and understand the issues surrounding escalating costs and the need for cost-containment. They must be thoughtful in ordering diagnostic tests, avoiding the overuse and misuse of imaging studies and laboratory tests that have become rampant in health care. They must avoid duplication of studies and must be conscious of opportunities to prevent avoidable hospitalizations or readmissions. In short, they must become part of the solution to control health care costs, not only for today but for the rest of their professional lives.” What are the biggest hurdles in making this happen?
Weinberger: There are several hurdles that I can name: 1) habits learned earlier in training that are hard to break; 2) time – both to spend with patients to explain why a particular test or treatment is not necessary, and time for the type of teaching done through observation of residents in the direct care of their patients; 3) insufficient faculty preparation or training to serve as the instructors and the role models; 4) pressure to get patients out of the hospital quickly, so that it is often felt that as many diagnostic tests and consults that might be needed during a hospitalization should be ordered as soon as possible on admission.
MDSI: In the Annals article, as well as in a piece you wrote in the Philadelphia Inquirer, you seem to focus on diagnostic testing. Why is that?
Weinberger: Diagnostic testing is indeed only part of the problem; treatment is the other major piece. We focused initially on diagnostic testing because we thought it would be less controversial and likely to raise questions of “rationing.” However, once we move to the treatment area (which we are in the process of doing), we are still not talking about rationing, but rather talking about avoiding unnecessary treatment that does not help patients. Rationing means withholding care that can help patients.
MDSI: How can physicians be stewards of resources while protecting themselves against malpractice lawsuits?
Weinberger: At the same time we develop guidelines and educate physicians, we need to educate patients that doing more is not necessarily doing better for them. As we develop more in the way of guidelines and recommendations, we also feel that having these standards of practice come out from a national organization like the American College of Physicians will hopefully provide some liability protection for physicians who are following the recommendations to provide what is considered to be appropriate care.
MDSI: Do you anticipate resistance to your suggestion of the seventh competency? If so, why? What will be arguments against adopting it?
Weinberger: It’s not easy to get the regulatory organizations (in this case, the ACGME) to change. Also, cost-consciousness does exist as a small subcomponent of one of the current competencies, but the fact that it is not prominent means that it often is ignored, or its importance is not emphasized. In fact, the comments I have received have been almost uniformly positive. Even if a seventh competency is not established, I think that raising the question and emphasizing the importance of the area will hopefully have an impact on changing behavior in the training environment.
Questions physicians should ask themselves before ordering tests
The Congressional Budget Office has estimated that up to 5 percent of the nation’s gross national product is spent on tests and procedures that do not improve patient outcomes, according to a recent editorial in the Annals of Internal Medicine, a publication of the American College of Physicians. The sixth edition of the ACP Ethics Manual calls out responsible stewardship of resources as an ethical responsibility of physicians. “Such stewardship requires substantial and persistent effort with some hard decisions along the way,” according to the editorial. “Addressing a few simple questions before ordering a test seems to be a reasonably easy way to start the journey toward high-value care.”
Following are suggested questions physicians should ask before ordering tests, according to the ACP:
Source: Annals of Internal Medicine, 17 January 2012, Vol. 156, No. 2, page 163.