Response to the 2011 Question of the Year
The nation teeters on the precipice of financial insolvency. Health care costs darken the economic horizon. Public trust in medicine is at an all-time low. Meanwhile, medical educators reconfigure their curricular cornerstones at a dizzying rate. Basic science course work is integrated with clinical, training with delivery, undergraduate with graduate and CME, education with mission, and the formal with the multitude of other-than-formal dimensions of the educational citadel. Competencies, milestones, and landmarks are being created, catalogued, and coordinated. In the end, however, none of this will matter. Whatever the pedagogical fix, one largely ignored, if unintended, consequence of medical education remains indelible. Medical training has become an institutionalized process of elevating an already privileged (educationally or otherwise) group into an even more elite social class. Trust may be withering, but power and privilege (particularly when it comes to defining, diagnosing, and treating disease) remain. Meanwhile, patients and their families fear retribution if they question their doctors.1 A rift between the public and those sworn to serve their needs deepens.
Key to this alienation is that physicians lack insight into the economic and social burden of the services they orchestrate.2 As a consequence, the most pernicious threat to health care and medical education in the United States today is not patient safety, nor the lack of an evidence-based practice, but rather the alienation of trainees and physicians from the financial cost to patients of their work.
We propose, therefore, a training process organized not around disciplines, organ systems, diseases, or clinical problems, but around cost. Beginning with the admission process, all medical school applicants will be required to demonstrate proficiencies in micro-, macro-, behavioral, and health care economics, and to document community service and related shadowing experiences in clinic business offices or sites related to the recording and payment of medical charges. A new MCAT exam, Kaplan course work, and premed advising will all mirror this shift.
On matriculation, all students will begin their training with a range of focused educational activities designed to increase and improve their “cost-consciousness.” To this end, the medical school (and not just the curriculum) will be reorganized so that all members of the educational community are grounded in an experiential understanding of cost and its relationship to health care access and the burdens of treatment.3 Administrators must learn how to create and present translucent budgets and to coordinate those budgets so that they reflect the values of affordable and trustworthy medical care. Faculty (and this means anyone coming in contact with a trainee in his or her capacity as a teacher/facilitator) must become “cost literate” prior to working with students. Faculty development programs must be developed to these ends.
The first two months of medical school (with preexisting courses taxed to create this curricular space) will be devoted to the economics of care. This block will involve multiple pedagogical approaches from traditional didactics and problem-based learning to simulation and social networking. Instructors will range from topic experts to patients and members of the public whose lives are being bludgeoned by health costs. Preceptorships will be community based and will focus on student experiences in educating the public on the cost of both schooling and health care. Once this competency is mastered, students will begin to meet with patients upon discharge (clinic or hospital) to explain all charges. There will be no traditional “patient care” contact until students are fully able to decode and explain the highly cryptic billing statements that encumber patients. As students enter the biomedical side of their training, patient meetings will begin to add explanations of diagnoses and treatment options to those of cost. No student will be admitted to the care side of the educational continuum until he or she is fully able to explain to patients what has been done to them and why. As students move into residency training, they periodically will be shifted from their clinical responsibilities into the discharge process to recheck on their decoding and explaining competencies. National boards will reflect this new mandate. So, too, will CME requirements, which will include mandatory credits in cost competency. Cost will be defined as a major burden of treatment, with “burden of treatment” a major reframing of how we conceptualize and approach health care.3
We seek to provide a system of training that will produce true patient-centered practitioners, a bona fide revolution in what it means to practice medicine, a physician workforce prepared to lead, and a true profession willing and able to regulate itself on behalf of the public.
1 Dowd M. Giving doctors orders. New York Times. April 13, 2011:A25.
2 Cooke M. Cost consciousness in patient care—What is medical education's responsibility? N Engl J Med. 2010;362:1253–1255.
3 May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ. 2009;339:b2803.