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.