An estimated one-third of health care costs—about $750 billion—don’t actually improve health, according to the Institute of Medicine (IOM). Residents’ exams often ask them to choose the “one best test” for diagnosis to avoid health care waste, but what if the real-world choice is “all of the above”?
“Trainees watch role models take a ‘do-everything-at-once’ approach, often just because they can,” said Sharon Rikin, MD, a member of the AMA Resident and Fellow Section (RFS) Committee on Science and Public Health. “Often we are too far removed from the actual money exchanging hands to see the necessity of practicing cost-effective medicine.”
According to Choosing Wisely, reasons residents and other physicians may over-order tests include:
- Concerns about medical liability
- Just to be safe
- Securing additional information as reassurance
- Patients insist on specific testing
- Keeping patients happy
- Not enough time with patients
- Fee-for-service system
- New technology in practice
Residents also have pointed to such reasons as duplicating behavior they have seen role modeled, a lack of knowledge of the costs and harms, or limited training in weighing the benefits relative to the costs and potential patient harms.
To address health care waste, institutions are incorporating cost-effective medicine curricula into training for medical students and residents. Programs like “High value cost-conscious care,” from the American College of Physicians and the Alliance for Academic Internal Medicine, provide a way to train physicians in cost-effective care.
The Choosing Wisely campaign, created by the American Board of Internal Medicine Foundation, aims to promote conversations between physicians and patients by helping patients choose care that is evidence-based, non-duplicative of other tests or procedures, and above all, truly necessary. Specialty medical societies have provided lists of the top five things physicians and patients should question, offering a guide for physicians in training.
“Initially, the cost of a basic metabolic panel is shocking, but eventually it fades and the ordering of ‘daily labs’ reoccurs,” Dr. Rikin said. “As a senior resident myself, I hope to role model appropriate stewardship of finite health care resources. As I discuss my expectations with my team, I ask my interns to question what labs we order on a daily basis, and I task my medical students to identify potentially wasteful tests.”
Residents are taking health care waste to heart, as exemplified in a recent op-ed in The Tennessean by two residents at Vanderbilt University Medical Center. In the first three months of Choosing Wisely implementation, Vanderbilt eliminated more than 1,000 unnecessary tests and saved nearly $150,000.
“What residents may lack in experience is more than made up for through their eagerness to do the right thing, their pursuit of knowledge and strong sense of compassion for patients,” the op-ed said. “Residents have recently graduated medical school equipped with the most up-to-date knowledge and are eager to read the latest research and constantly challenge the system to remain on the cutting edge of medical treatment.”
The AMA Section on Medical Schools recently examined health care resource stewardship, including how medical schools could ensure physicians-in-training learn to practice high-value, cost-conscious care. Find more information on the AMA Section on Medical Schools Web page.
