Cost should no longer be a dirty word in medicine

I strolled into our noon-daily resident conference, a little late, my free burrito in hand, and noticed that “cost awareness” was the topic. The conference seemed to have the same format as our other lectures: an attending was presenting a clinical case and asking us what steps we could take to best diagnose and manage the patient. The case seemed straightforward enough—a 65-year-old healthy Caucasian gentleman with right-sided chest pain—and the attending asked us what we would do next? Low-risk, I thought to myself, and joined the room in shouting out “EKG!” But the next question was met with awkward silence. How much did that EKG cost?

Before I went to medical school, I was a teacher. In that role, I was painfully aware of the cost of each item—the glossy textbooks, the school’s utility bills, the low teacher salaries. As a resident focusing on underserved populations, I prided myself on my ability to recite the $4 Target medication list from memory. Since I knew which medications were most affordable to my patients, I figured this must translate into some knowledge about medical costs overall. After all, don’t most other jobs require you to know the prices of the products you sell?

The presenter stared directly at me. “So how much will this EKG cost?” Two months into intern year, having ordered at least one EKG per day on the inpatient service, I still had no clue what we charged for them. Doing some rough calculations in my head, estimating the approximate costs of the machine, paper, and nurse involved, I tripled my estimate—after all, things cost much more than they should—and blurted out, “A hundred bucks.” My neighbor got called on next and volunteered $500. Around the room we went, with guesses varying from $25 to $600. It was clear that I was not alone in being clueless about cost awareness, and that we could use some help.

The UCSF Cost Awareness curriculum was implemented in June 2011 by a fellow UCSF internal medicine resident, Dr. Chris Moriates, along with Dr. Krishan Soni, UCSF Chief Resident for Quality Improvement and Patient Safety; and Dr. Andrew Lai, UCSF hospitalist faculty. Through a series of interactive and innovative lectures, the curriculum challenged our assumptions about the costs of care and made us wiser clinicians.

Naysayers argue that we physicians should be blind to the costs of treatment, citing concerns that high costs could prevent us from ordering necessary tests or medications. But the purpose of this curriculum is not to teach rationing health care; it’s to teach rational health care. By learning the fundamentals of evidence-based medicine, but keeping the best interests of the patient in mind, we’ve learned how to use the most current guidelines to provide individualized yet cost-effective care. We’ve learned how to properly risk-stratify patients, consider pre-test probabilities, and yes, defer that expensive vasculitis lab test after pursuing a more logical stepwise work-up. We’ve learned how to take the patient in front of us and try to judiciously apply the most current and rigorous guidelines to the individual care of that patient, while at the same time making clinical decisions by accounting for various risks and probabilities.

We see firsthand how unnecessary testing costs our patients more than just money: anxiety from unnecessary biopsies, anemia from excessive blood draws, infections from needless procedures, and radiation from repeated CT scans. We see physicians ordering tests for fear of “missing something now” and leaving the long-term financial and physical costs for later. And we worry about how health care consumes 18% of our GDP, $750 billion of which the Institute of Medicine has categorized as health care waste.

“Cost” used to be a dirty word in medicine, but with local efforts like Dr. Moriates’ cost-awareness curriculum and national efforts like ABIM’s Choosing Wisely campaign, these issues are rightfully coming more to the forefront. Little did I know that one free burrito would lead to a new way of considering the impact of a $150 EKG in clinical care, but I’m glad it did.

Lekshmi Santhosh and Alicia Carrasco are internal medicine residents who blog at Primary Care Progress.

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