Learning about costs: A gross failure in medical education

Of the 2.7 trillion dollars that will be spent on health care in these United States in 2012, more than $600 billion will be wasted.  Excess testing and procedures, inflated charges, archaic business models, futile end-of-life care and exploding drug costs are some of many reasons.  Predicted 25 years ago this crisis has been the focus of extensive academic analysis.  It is reasonable to assume that with the primary goal of helping our country afford medical treatment, modern medical students are given extensive training in quality, cost containment and efficiency.  Apparently not.

In a fascinating and surprising paper in the journal Health Affairs, researchers find the most recent medical school graduates actually spend more treating their patients. The analysis shows that each decade a physician is in practice their costs decrease. Physicians in practice less than 10 years spend 13.2% more than physicians with forty years of experience.  There was no relationship to any other factor, such as malpractice claims, board certification or patient mix.  Simply put, medical schools have not learned that there is a need to reduce cost and do not teach this lesson to their students. It is only when physicians gain wisdom in the actual practice of medicine, that their experience saves dollars.

The article does not break down in any detail the reasons for this gross failure in medical education, leaving us to await further research and, for the moment, to guess.  Having served as voluntary medical school faculty for 26 years, I have an observation.  Students are exposed to massive technology in the form of new drugs (expensive), new tests (more expensive) and new therapies (extremely expensive) and in the flood of techno-learning little time is spent on balancing the latest and greatest with basic concepts such as the physical exam, counseling and decision making.

When I went to medical school (grad 1981) the encyclopedia of drugs, known as the PDR, was 2 inches thick.  Now it is 6 inches thick but pharmacy class in medical school is exactly the same length. Thus, students spend most of their time memorizing lists, instead of differentiating therapies.   There has been the same explosion in surgical techniques (transplant, robotics, laparoscopic…), radiology (MRI, PET, CTA, invasive procedures…) and pathology (cytogenetics, immunoassays, monoclonals…).  Academic careers based on a publish or perish model are often biased to produce more complex and expensive discovery.  As medical schools focus on research and development instead of the excitement of analysis and the teaching of efficient quality based medicine, they put our entire healthcare system in jeopardy.

Now, the good news is that with experience, there is a drop in cost.  That means that as doctors learn via the practice of medicine they apparently provide better and more efficient care.  Thus, it is possible to use judgment to produce high quality results at less cost.  The question is will we teach it?

If we are going to save those 600,000,000 yearly dollars, academic medicine (i.e. medical schools) must understand that the best medicine, the most efficient medicine, the highest quality medicine, is not produced simply by throwing the latest technology at the problem.  The best medicine is the result of a balanced study of therapy, measuring result, cost and quality, to find the best care at the least cost.  America was not made strong by producing the most expensive luxury cars, but by producing quality cars at a reasonable price so that all could benefit. By this method not only will we be able to afford medical care, but the care we give will result in a healthier population.

The future of healthcare depends on spending our dollars wisely and it must start by the training of young physicians. While it is vital that research produce innovation, if medical schools continue to ignore their responsibility to teach concepts of affordable care, we will not be able to afford the mythical healthcare we produce.  Our young doctors must be the leaders in this medical revolution and our medical schools must show them the way.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • Bryan Adams

    Thanks for sharing such a nice blog with the people.

    Our young doctors must be the leaders in this medical revolution and our medical schools must show them the way. It’s really a true wording.

  • meyati

    I know a certain oncologist that Dr. Salwitz should sit down with and talk. I’m 71, and the idiot wanted to ship me out of state, cut out my nose, upper sinus, cheek bone, eye. Then maybe take a year for a prosthetic face. He said I’d even get physical therapy. What would happen to my body? How would this wound be taken care of? I asked about palliative care-and he tried to bully me by saying I couldn’t get it. I have bone drillers around my nose-and surgery seems to activate them. Part of my fear was that with the political scene, that my care would be stopped in the middle. I began filing complaints in an administration that kept putting me off. I finally said -lawyer and state medical board–I got a new doctor in a hurry. I kept saying this doesn’t make sense. There isn’t any cure- I should be given pain killers to make me comfortable and to ease my pain.

  • bill10526

    Efficacy trials look for changes that are true improvements. To the extent that the trials are effective, rational behavior calls for using the latest and the greatest.

    Of course costs should be considered.. Treatment B might be measurably better without its benefit being cost justified.

    A secondary but real problem comes from some doctors and governments waiting for the generic. That attitude spreads R&D over a narrow base. The cost savings that Canada negotiates are income transfers from American saps.

  • Robert Goodhope

    Here is an excess testing trial balloon: Low Hanging Fruit

    This is not a proposal to reduce the number of glucose strips for insulin using diabetic patients.

    Read the above statement again.

    In 1997, Medicare allowed diabetic patients whether using insulin (15%) or not using insulin (85%) free access to glucose testing strips for self monitoring of blood glucose (SMBG), The costs of unlimited SMBG in non insulin using Medicare beneficiaries is $6-8 Billion dollars annually. The average benefit of recommended frequent SMBG in non insulin using patients is only a 0.25% reduction in Glycosolated Hemoglobin compared to those not using insulin and not testing frequently.

    The reinforcement of diabetic education and counseling is often offered as the rationale for the routine frequent use of SMBG and differences in diabetic parameters cited above is offered as justification. An Iranian study showed that quantitative benefits of diabetic education can be maintained with only two evening post prandial self glucose testings a week in those not using insulin as treatment. For a dozen years, the VA health system has limited non insulin using diabetic patients to 200 glucose test strips a year. The measure diabetic parameters of non insulin using VA have not deteriorated in that time.

    A Canadian study of their system’s third largest category of medication costs, glucose test strips, projected the economic benefit of reducing glucose strip testing to twice or four times a week in non insulin using diabetic patients against the mounting evidence of no medical harm by so doing.

    Based on the above, non insulin using diabetic Medicare beneficiaries could be reduced to no more than 200 or 100 test strips a year, without losing the benefits of diabetic management. As a result 4-6 billion dollars annually could be excluded from the US health care budget without expectation of causing clinical harm. More importantly, this is also a potential $ 6 billion, no penalty, reduction in Federal entitlements which help balance Medicare and help mitigate the $85 billion sequestration penalties.

    This is not a proposal to reduce the glucose strips for insulin using diabetic patients. Please read this preceding sentence again

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