Counting the Cost

Edition: March 2012 - Vol 20 Number 03
Article#: 3941
Author: Repertoire

The need to improve quality of care and to ensure patient safety are key issues facing the medical profession today. But doctors are facing a new elephant in the room, which may be just as critical to acknowledge: the unsustainable cost of care.

Writing in the Annals of Internal Medicine (Sept. 20, 2011), Steven Weinberger, MD, executive vice president and CEO of the American College of Physicians, calls for medical schools to teach residents the need for stewardship of resources and practicing in a cost-conscious fashion. “It is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of healthcare costs,” he writes.

Specifically, Weinberger is calling for a new “general competency” for medical residents, which would call for residents “to 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 healthcare costs.

The proposed competency would be the seventh competency for medical residents. The existing six were defined 10 years ago by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties. They are:

  • Medical knowledge. Resident should demonstrate knowledge of established and evolving biomedical, clinical, epidemiologic and social-behavioral sciences, as well as the application of this knowledge in patient care.

  • Patient care. The resident should be able to provide patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health.

  • Professionalism. The resident should demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

  • Interpersonal and communication skills. The resident should demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families and health professionals.

  • Practice-based learning and improvement. The resident should demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.

  • Systems-based practice. The resident should demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

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:

  • Did the patient have this test previously? If so, what is the indication for repeating it?

  • Is the result of a repeated test likely to be substantively different from the last result?

  • If the test were done recently elsewhere, can I get the result instead of repeating the test?

  • Will the test result change my care of the patient?

  • What are the probability and potential adverse consequences of a false-positive result?

  • Is the patient in potential danger over the short term if I do not perform this test?

  • Am I ordering the test primarily because the patient wants it or to reassure the patient? If so, have I discussed the above issues with the patient? Are there other strategies to reassure the patient?

Source: Annals of Internal Medicine, 17 January 2012, Vol. 156, No. 2, page 163.