How can we encourage medical residents to truly choose wisely?

As Dr. David Green reported recently in NEJM Journal Watch, the American Society of Hematology is the latest society to comment on appropriate and cost-conscious care in the ABIM Choosing Wisely campaign. I’ve followed the Choosing Wisely campaign closely and have been using it on the wards and in clinic as academic ammunition. A specialist society’s public advice about showing restraint is an excellent means to challenge the dogma of our so-called routine practices.

I know every conscientious practitioner has struggled with the high price of medical care. Our training environments are currently breeding grounds — and battlegrounds, for that matter — for ideas on how to solve our nation’s cost crisis. I have often wondered how we might change the way we train our residents and teach our students to exhibit financial diligence.

Of course, we are all part of this economic mess, and residents rightly share some of the blame. As naïve practitioners who lack confidence in diagnosis and management, residents tend to overorder and overtreat. I certainly have checked a thyrotropin (TSH) level in the inexplicably tachycardic hospitalized patient, despite my own knowledge that it was probably worthless. And I’ve seen colleagues get echocardiograms “just to make sure” they could safely administer large amounts of IV fluid for hypovolemic patients with hypercalcemia or DKA. When residents don’t have years of experience, they use high-tech diagnostic testing as a crutch.

Then again, the expectations of the learning environment also contribute to the epidemics of excessive echocardiograms and needless TSH levels.  First of all, trainees are expected to have their patients presented in neat  little bundles, devoid of any diagnostic uncertainty. Additionally, they have been trained through years of positive reinforcement for broad differential diagnoses and suggesting additional testing for unsolved clinical problems.

Although the Choosing Wisely campaign speaks to me and many of my generation, it is only a start. It alone cannot stand up to the decades of decadence and our culture of waste. How can we encourage trainees to truly choose wisely in the training environment?

I propose the following:

Deploy pre-clinical curricula that emphasize value-based medical decision-making. As much as students lament the breadth and depth of their curricula, pre-clinical students have fresh, open minds and are actually receptive to learning about cost-consciousness. We cannot expect that the curricula in residency or CME efforts will have an effect on our cost-ignorant model of care.

Include cost-conscious ordering and prescribing in our board examinations. I have seen some change from when I took the USMLE Step 1 in 2008, but I notice that clinical board questions still usually ask for a “best next step” that usually doesn’t include “expectant management” as an option.  As trainees prepare for these exams, they develop a line of thinking that then permeates clinical practice. When patients with chronic musculoskeletal complaints and unremarkable radiographs are referred for MRIs rather than receiving reassurance, we can put some of the blame on our licensing exams.

Reward trainee restraint. Residents and students should be commended for not working up insubstantial problems, withholding unnecessary treatments, and showing prudence in choosing diagnostics. Again, our educational constructs are to blame, because we reward expansive thinking and “not missing” things. In morning reports and other case conferences, we often praise residents for adding another diagnostic possibility rather than exhibiting “diagnostic restraint” or cost-conscious care.

Give trainees some sense of the cost and price of tests and treatments. The literature has not consistently shown that giving physicians cost or price information will prevent wastefulness. But as far as I know, these studies have focused on clinicians in practice who are wedded to their ways. From my experience, trainees thirst for this type of information. Frankly, we are all clueless about how much a chest CT costs. How much was the machine? Are there separate bills for the scan and for the radiologist’s interpretation? How much is the patient expected to pay? What will insurance pay?

Get leadership buy-in at academic centers. I am neither a healthcare economist nor a chief financial officer. But my experience as a chief resident has taught me that buy-in from the academic leadership is necessary to turn the tide on monumental tasks.

Paul Bergl is an internal medicine physician who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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  • Dr. Drake Ramoray

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    I certainly have checked a thyrotropin (TSH) level in the inexplicably tachycardic hospitalized patient, despite my own knowledge that it was probably worthless.
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    Bwa ha ha ha ha. At every Endocrine Society conference in recent memory there is a section where us lowly clinicians get to present a case with a salient teaching point. Almost every year there is a case with someone who gets a multi-thousand dollar work up and the missing test is a TSH. This is not a board question, it’s real world. Patients who can’t come off the ventilator. MRI, CT, test after test after test, and then they have a TSH of 50. There are similar cases with undetetcably low TSH levels. Unexplained weight loss with thousands of dollars spen on workup for cancer. I just checked with my office manager a TSH in my office costs $32

    This article is very long and leaves out three very imporant considerations. Litigation, and patient wishes. The desire for the most new fangled testing, or even test everything I don’t know what’s wrong with me, is undeniable. Couple this with physicians being graded on “satisfaction scores” and third party payers and you have a recipe for needless testing. This of course just adds fuel to the fire for defensive medicine.

    Let me give you a real world lititgated case where the physician lost. A urologist took a patient at his word that he didn’t have diabetes and didn’t order a UA prior to a routine urological procedure. The physician then lost a malpractice case because he didn’t order an “unnecessary test.” The patient claimed that he didn’t understand that diabetes meant his blood sugars were high and that his doctor had always told him he had a touch of pre-diabetes. This patient subsequently suffered a long and debilitating recovery from the procedure and while there were other mitigating factors but had this surgeon ordered a standard UA prior to this procedure the whole case may have been avoided.
    Lastly, given the push to shorten residency, the falling board scores of current graduates, my interactions with physicians who are within a few years of training, and shortened work hours, I’m not optimistic that this will become part of the curricula. First do no harm. Second rule out badness. Third don’t order a test that won’t change what you are gonna do. Seems simple enough, and didn’t require a comittee to come up with. Has medical education really fallen so far?
    Oh almost forgot, the third one. The real problem is third party payors and lack of price transparency. I found out that TSH cost in 25 seconds, half of which was spent walking down the hall. How long will it take you to find out how much it costsw at your institution?

    • azmd

      Too long for it to be worth my time to find out, which then, as you correctly comment, is a significant barrier to my factoring in any cost-benefit analysis into the three seconds that I have to think about whether to order the test or not…

  • Steve

    As someone only a year and a half removed from residency this article rings true but it’s complicated because of the wide variation in practice patterns. The change needs to start at the attending level and work its way down. With residents working with different attendings month to month (or even day to day in the ED) I had several instances where I proposed reasonable courses that would save testing and was looked down upon because that particular attending thought I wasn’t being thorough where another one would praise me for my efficency.
    Now that I am out practicing on my own I can “light my corner” and cut down on wasteful testing (which may or may not be undone by the admitting team) but as a resident this is very difficult. It takes a lot of courage to not order that test- it can be done but residents need to be coached to explain their reasoning. Even when the reasoning is explained it’s often dismissed by senior staff who are set in their ways and then the resident appears ‘weak”.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I think there is probably another thing hospitals could do to overcome “decades of decadence and our culture of waste” and that is to bring the price of all these tests more in line with their actual costs. How much does a $32 TSH cost at the hospital?

    • southerndoc1

      Exactly.
      The problem isn’t that residents are ordering too many tests, it’s that the institution bills for them at highway robbery rates (and then adds on a facility fee).

      • azmd

        But, like lots of other things in medicine these days, doctors are taking the blame, partly because we are all told that doing anything other than accepting all the responsibility all of the time is “making excuses,” and not being “accountable.”

        It sort of mirrors what’s currently going on in the education world, and we all see how stellar those results have been…

  • doc99

    Meaningful Tort Reform would be the carrot in this buy in, as opposed to Re-education Camps for those costly “Outliers.” Even if the perception of risk is higher than the actual, as the Andre Agassi Canon ad proclaimed, “Image Is Everything.” To quote another learned physician, “Quid Pro Quo, Clarice.”