A few months ago, I went to a talk by a health economist. “How many of you think cost will factor into your decision-making with patients?” he asked the audience of medical students. About 80 percent raised their hands. Surprised, he commented that when he asked that question ten years ago, maybe 20 percent of his audience raised their hands. “Then again,” he joked, “maybe you are only saying ‘yes’ because you know I’m an economist.”
It is difficult to consider a career in medicine today without an awareness of spending. Go to any talk on health care policy, and you will hear a similar message. Health care spending is increasing at an unsustainable rate. The United States spends more per person on health care than any other nation, and yet we are not any healthier for it. If we continue to spend at current rates, we will jeopardize the long-term fiscal stability of our nation. Something is broken. Something needs to be done. Physicians are partially responsible for doing something.
Despite these facts, a common mantra is that medical students are wholly unprepared in this regard. Last week, Dr. Pauline Chen published a piece in the New York Times on a new teaching module that will train doctors to think more about costs. “Today… doctors continue to struggle to reconcile cost consciousness with quality care,” she writes. “And doctors-to-be are not getting much help in learning how to do so.”
If that was true in the past, steps are being taken to improve the situation. In 2006, Harvard implemented a month-long health care policy course into the first year curriculum. We also take a semester-long ethics class, where the subject of cost and how it plays into patient care comes up often.
A few weeks ago, we turned to rationing. We met a fictional 28-year-old office worker who came to the doctor’s office complaining of headaches. Her symptoms fit the classical pattern for tension-type headaches. Yet, worried about a brain tumor, she asked for an MRI. The MRI would cost $1,500 to $2,000, and it would come out of the budget for the rest of health maintenance organization (HMO) patient population. What should we, as doctors-to-be, tell her?
Many of us thought that the rationing line has to be drawn somewhere, and this seemed like a pretty good place. With the chances of a brain tumor in this case “vanishingly low,” the MRI struck us as having a pretty poor benefit-cost ratio.
Still, change a few circumstances – such as making the likelihood of the tumor slightly higher than the stated “vanishingly low” – and my feelings about the situation became more complicated. It was easy for some of my classmates to continue to write the patient off as neurotic, but I sympathized with her. What’s so wrong about being health conscious?
All this just goes to show that there is no clear right or wrong in terms of being cost-conscious. There is no model to learn and follow. We read. We debate. We disagree. We try to identify what can be resolved by data, and what is a value judgment. We challenge one another’s assumptions, along with our own.
I do realize discussing these patients in the abstract won’t necessarily ensure good decision-making when we get into clinic. It is easy to sit around a classroom and debate whether we should give a fictional patient an expensive test under X, Y, and Z circumstances, but quite another to routinely integrate cost, among all other clinical factors, into daily practice. I imagine it will be far more difficult to look a concerned patient in the eye and say no, I cannot provide this service you are requesting. It will be difficult because to cite any reason for denying the service other than cost would be dishonest. And acknowledging that money is a limiting factor in health care is a tough thing to accept.
But, it’s a good thing we are having these discussions now. I am grateful that medical education is becoming more well-rounded, and that I will not be thrust into caring for patients with a strong knowledge of the nuts and bolts of clinical medicine but without benchmarks of what’s reasonable in terms of cost.
Because as much as we might shun cost as a dirty word, antithetical to the noble aims of the physician, it will be relevant to all of our practices.
Image: From Wikimedia Commons