This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States. The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!). How could I follow that…especially with a talk on how to train cost-conscious physicians? Those who know my work well may even wonder how I got invited to talk about this. Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees. In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.
- Faculty are not trained. The largest barrier of course is that faculty don’t know how to do this. A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
- No one knows what the cost of anything is. Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost. In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
- Bad systems promote costly workarounds. Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge. The system is set up to order the test even if the attending thinks about it. Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
- Rumors and hospital legends spread quickly. The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.
- Underordering, not overordering, is penalized. Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis. More reasons doctors over-order tests here.
So what can we do to teach residents about cost-conscious practice? Well here are just a few of the things we can do..
- Empower residents to find out how much their hospital charges for things. As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs. Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
- Show residents how much they spend. At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks! Studies with electronic health records at the point of care show even greater results!
- Use unbiased resources that promote better cost-effective decisions. Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities. The popular 4 dollar list for medications is another example.
- Incorporate discussions of costs into routine educational conferences. At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like. In our medical student lectures on radiology, the costs of the tests are also now discussed.
- Educate patients that less is sometimes more. Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine. The pushback from patients may be the fear of rationing, which is of course irrational since it already occurs. A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.
As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine. The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed. This is especially important to watch out for as burnout sets in late in the academic year. So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.
–Vineet Arora, MD
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