By Richard M. Schwartzstein, M.D. and Grace Huang, M.D. http://bit.ly/15Ww2hN
Richard M. Schwartzstein, M.D., Executive Director of the Carl J. Shapiro Institute for Education and Research, Vice President for Education at Beth Israel Deaconess Medical Center, and Faculty Associate Dean for Medical Education at Harvard Medical School
Grace Huang, M.D., Director of Assessment at the Shapiro Institute and Assistant Professor of Medicine at Harvard Medical School
No topic is more timely or relevant to the current political climate than cost-effective care. We at the Shapiro Institute for Education and Research prefer to frame the concept as “value-added care,” which incorporates patient-centered outcomes, including potential harm and discomfort from diagnostic testing. In the face of data that demonstrate wasteful testing and treatments contribute significantly to our rising health care costs, practicing physicians are under pressure to be part of the solution.
The lay public clearly is attuned to this crisis as expressed in the popular press and media reports and is demanding to know why physicians are not taught to consider the value and cost of the tests and treatments they recommend. Changing physician behavior, however, requires more than knowledge-based instruction; rather, we must identify and address the cultural factors that contribute both to patients’ demands and expectations and to physicians’ actions.
Our historical model for training physicians has neglected to incorporate contemporary principles of resource utilization, harm from diagnostics, and cost considerations into medical education curricula. The medical, physical, and emotional consequences of false-positive testing are not real to medical students. Even in the hospital environment, where trainees become increasingly aware of delivery issues—such as readmission rates, observation status, and case management—they still operate under assumptions that tests and services are fully reimbursed and that hospitals are profitable. Consequently, when residents enter the workforce, they are unprepared for the economic realities of our health care system and typically lack the tools necessary to navigate an optimal patientcentered, cost-conscious approach to the evaluation and management of their patients.
Topics such as epidemiology, evidence-based medicine, and diagnostic reasoning represent the cornerstones of the preclerkship curriculum for medical students. But the hidden curriculum and test-ordering practices of attending physicians (who often drive the ordering decisions of trainees) hinder the effective application of these theoretical principles during actual clinical experiences. Most faculty members are neither trained in high value care nor able to identify “best teaching practices.” Academic doctors, particularly those practicing in tertiary medical centers, strive to teach their students and residents the breadth and depth of medicine. The longer and more intricate the differential diagnosis, the better, and supervising physicians often are loath to stifle the curiosity of their trainees.
Patient expectations fuel excessive testing. The fear of malpractice litigation may incentivize health care professionals to pursue diagnostic certainty even at the cost, both financial and human, of multiple tests and procedures. Physicians may assume that patients will seek alternate care if their doctor is reluctant to pursue whatever test the patient thinks is necessary, regardless of the cost. Physicians also may opt for the perceived “easy way out” by giving the patient what he or she wants, rather than entering into a thoughtful, but timeconsuming and potentially difficult, conversation about the reasons for avoiding that diagnostic pathway.
There have been positive steps to reduce waste and contain costs. Campaigns such as Choosing Wisely at the American Board of Internal Medicine have spurred professional societies to highlight unnecessary tests for their specific specialties, while the High-Value Care Curriculum at the American College of Physicians (ACP) provides the knowledge elements and tools to deliver content. But these initiatives, although incredibly valuable starting points for these discussions, may not sufficiently address our medical culture, which demands diagnostic certainty. One key question remains: If we want to influence the actions of future physicians, how do we optimally teach these principles to our current trainees?
In this context, the Shapiro Institute convened an invitational Millennium Conference on Teaching Value-Added Care, co-sponsored by the AAMC and in partnership with the ACP. This spring, teams from six medical schools—Drexel University College of Medicine, Dalhousie University Faculty of Medicine, Geisel School of Medicine at Dartmouth, Case Western Reserve University School of Medicine, Penn State College of Medicine, and Mayo Medical School—joined the Harvard/Shapiro team to consider challenges of the learning environment, propose best instructional practices, and engage in a structured dialogue to build consensus on how to teach value-added care across the medical education continuum.
We will detail our findings in future proceedings. A preliminary summary includes the following highlights.
Value is not strictly about cost; it comes from the patient’s perspective. As such, we must teach and serve as models for the behaviors that elicit patient concerns and preferences about the many nonmedical factors that influence their perceptions of health care. To explain why a particular study highlighted in the media does not apply to an individual patient requires not only knowledge of study design and biostatistics, but also the ability to translate that information to a patient who may not fully understand the study results. Discussing the complications of testing, particularly the consequences of false-positive findings, is challenging and requires a range of communication skills.
Teaching value does not necessarily require significant amounts of extra time.When a test of questionable value is ordered, ask the student or trainee, “How will the results affect what we will do with this patient?” At the end of patient rounds, consider adding questions that foster appropriate test ordering, such as, “Is there anything we ordered today that the patient does not need?” During the traditional morbidity and mortality conferences, add a discussion of hospital costs incurred.
Tackle the hidden culture head-on. The clinical learning environment is typified by routine daily labs, unnecessary diagnostic evaluations, and repeat imaging. Foster a reward system that values cost-effective care by discouraging extensive differential diagnoses that include diseases that are obscure and have a low probability of producing the patient’s clinical picture. Train a core faculty with demonstrated expertise in teaching these topics. Incorporate practice audits of ordering behavior into the teaching competencies of faculty.
The deliberations and recommendations of the committed faculty who attended the Millennium Conference 2013 are only the beginning of our efforts to enhance the teaching of value-added care. We hope our findings will stimulate additional initiatives across the United States and Canada.