The following post is by Brian Powers, an M.D. candidate at Harvard Medical School. Previously, he worked at the Institute of Medicine’s Roundtable on Value & Science-Driven Health Care.
After graduating from college I had the opportunity to spend two years working at the Institute of Medicine on a variety of health care improvement topics. When it came time to apply to medical school I noticed an odd dissonance—the challenges I had been grappling with at the IOM were not manifest in most medical school curricula. I knew that multidisciplinary teams deliver the best care, but I was going to learn almost exclusively alongside fellow physicians-in-training. I had learned that deficiencies in care delivery harm patients, but neither quality nor systems improvement would be areas of focus. The inattention to health care costs was particularly glaring. Rarely a day passed at the IOM where I did not attend a meeting, read an article, or work on a report that dealt with the cost crises in health care. But these challenges, and the physician role in cost containment, were absent from most school’s curricula.
I wanted to find a school that would allow me to build on my experience at the IOM, but I found it difficult to assess the extent to which schools were committed to teaching students about cost and value. Websites and curriculum catalogues quickly blend together, but I did notice that educational objectives offered an interesting glimpse of a school’s educational ethos. Unlike the standardized core competencies of residency programs, the Liaison Committee on Medical Education (LCME) allows medical schools to develop their own core educational objectives. The lack of standardization made these objectives a convenient way to gauge a schools commitment to preparing students for contemporary challenges in health care.
At the time I remember being disappointed by how few schools incorporated an understanding of health care costs and the physician role in resource stewardship into their educational objectives. Curious if these impressions were representative, I decided to take a more methodical approach and survey the educational objectives for a larger sample of medical school. What I found was unsettling. Among the top 25 research-focused medical schools, 50% include awareness of the economics and financing of health care in their educational objectives, and only 28% mention the role of physicians in cost control and resource stewardship. The picture is similar for the top 25 primary care-focused medical schools, where the results are 50% and 25%, respectively.
Acknowledging these deficiencies, leaders have recently called for better education on cost and value across the training continuum, particularly in residency training and the clinical years of medical school. But it is important to start earlier. There are two reasons this type of education should start on day one. First, it provides students with skills, knowledge, and time to grapple with the complex practical and ethical challenges of cost containment before they are in the position to make medical decisions. Students can then approach their clinical rotations with an eye towards high-value care, using practical experience on the wards to supplement and enrich a strong theoretical foundation. Second, focusing on cost and value early and often send a signal to students, and the medical community more broadly, that cost-awareness is a key competency for the modern physician. By making these issues core longitudinal themes, medical schools can build a culture of high-value care delivery among a new generation of doctors.
Resource stewardship and cost-effective care are widely endorsed as key components of physicians’ professional responsibility. As such, medical schools have an obligation to ensure that these principles are incorporated into their core educational objectives. Medical students deserve an education that will prepare them to meet the challenges of modern medicine.
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This is SUCH an important topic – medical schools don’t teach much of what doctors will need to know when they start practicing medicine, as an employee physician or as an independent practitioner. Your comment about the lack of training in resource stewardship has an effect on a doc’s ability to help a patient determine the real value of a treatment decision beyond alive/dead, which is certainly the value proposition at the top of the hierarchy of a patient’s medical needs. Yet most medical decisions don’t involve alive/dead, but they can put someone’s financial state on life support.
Thank you, and keep talking about this topic – it’s desperately needed.
Brian, I think you will make an invaluable contribution to the world of medicine. What you have discussed here is an important component of a larger issue about grounding medical training in the real world in which medicine is practices. An awareness of cost not only helps improve the value of medical care, it can also improve the quality of medical care. A doctor who does not consider the cost of the treatments prescribed is also not considering alternatives as broadly as necessary, and overlooks the fact that cost may mean that some patients simply don’t get the treatment prescribed. Sometimes the lower cost treatment might actually be more appropriate, but without the prompt of cost awareness, the doctor may never get around to considering it. Just as doctors have had to learn that compassionate end-of-life care does not violate their oath to “do no harm”, they also need to learn that considering cost does not mean they are devaluing life. By considering all the alternatives and their costs, they are ensuring that more patients will receive care. It means they value the quality of care AND quality of life for ALL patients.
Good article. Unfortunately, most medical school curricula are outdated the cost of care is not the only issue that should be introduced early.