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Educating Trainees About Appropriate and Cost-Conscious Diagnostic Testing

Weinberger, Steven E. MD

doi: 10.1097/ACM.0b013e3182308db7
Response to the 2011 Question of the Year

Dr. Weinberger is executive vice president and chief executive officer, American College of Physicians, Philadelphia, Pennsylvania.

Correspondence should be addressed to Dr. Weinberger, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; telephone: (215) 351-2800; fax: (215) 351-2829; e-mail:

Ensuring patient safety and improving the quality of care have been major challenges for health care providers, particularly during the decade from 2000 to 2010. In the current decade, however, reducing the ever-escalating costs of health care is rapidly assuming even greater importance, given these costs' far-reaching impact on the American economy. Efforts to transform the U.S. health care delivery system through such models as the patient-centered medical home are already showing promise for controlling costs by reducing the need for hospitalization and emergency room visits. However, an equally important transformation effort involves educating physicians about providing cost-conscious care and engaging them in a commitment to avoid overuse and misuse of care, particularly diagnostic testing.

An analysis by PricewaterhouseCoopers suggests that unnecessary testing is responsible for approximately $210 billion of wasted spending annually, or about 10% of the U.S. health care budget.1 This problem is growing over time: The volume of imaging studies and other tests per Medicare beneficiary has risen by approximately 85% since 2000.2 Many factors contribute to physicians' overuse and misuse of testing, including lack of guidance or guidelines, lack of knowledge about available guidelines, patient expectations, defensive medicine, duplication of diagnostic tests due to inadequate communication across the health care system, and habitual behavior that starts during training and persists throughout a career.

Minimizing inappropriate diagnostic testing not only controls costs but also improves patients' health by reducing the potential harms inherent in unnecessary testing or procedures. These harms can be direct—for example, radiation exposure from imaging studies that are not indicated or complications from invasive diagnostic procedures—or indirect—such as when an unneeded test finds an incidental, clinically unimportant abnormality and initiates a cascade of further testing, procedures, or treatment. At the same time, reducing unnecessary testing improves the population's health by conserving financial resources, thus reducing the ultimate need to control costs by withholding other, appropriate care.

The medical education community has the opportunity to play a critical role in addressing the overuse and misuse of diagnostic testing. Medical students, residents, and fellows need to be educated about appropriate diagnostic testing for the clinical problems they confront during training; such teaching should simultaneously reinforce the importance of the history and physical examination as tools to avoid unnecessary testing. However, equally important is changing the training culture to emphasize to medical students and residents that they are responsible for the stewardship and conservation of limited resources. Effecting such a culture shift will require faculty development efforts and a transformation of the behavior of faculty, who provide the models of care that trainees emulate.

The American College of Physicians (ACP) is addressing the issue of health care costs through its High-Value, Cost-Conscious Care Initiative, which is initially focused on diagnostic testing. The initiative's goals are to educate trainees, change physician behaviors, and address patient expectations and preferences so that these behaviors and expectations are more aligned with evidence-based practice. ACP's Clinical Guidelines Committee and other clinicians are identifying areas of overuse and misuse of testing, and they are publishing guidelines and guidance statements in the Annals of Internal Medicine.3,4 ACP is also incorporating information about appropriate diagnostic testing in its many programs and products to educate physicians and trainees.

Educating trainees and establishing a culture of cost consciousness can be accomplished most effectively through a collaboration of stakeholders. Within internal medicine, ACP is partnering with the Alliance for Academic Internal Medicine (the umbrella organization that includes department chairs, residency program directors, and clerkship directors) and the ABIM Foundation to develop and disseminate case-based and other curricular materials focused on appropriate diagnostic testing. These organizations are also working collaboratively to spread the message about reducing overuse and misuse of diagnostic testing, with the hope that such efforts will lead to a successful change in the culture of the training environment. For example, clinical educators need to incorporate into their daily supervision of students and residents such questions as “Why did you order that test? Was it the most appropriate and cost-effective test to order? What are you going to do with the results? Will it affect your management?”

Shaping the behavior of tomorrow's physicians so that they will conserve resources and avoid overuse and misuse of care must start with concerted efforts focused on today's students and trainees, and on the faculty who train them. The success of such efforts is critical to the health of our patients, the general population, and the health care system.

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The author wishes to thank Wayne Bylsma, PhD, and Allison Ewing for their helpful suggestions.

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1 PricewaterhouseCoopers' Health Research Institute. The Price of Excess: Identifying Waste in Healthcare Spending. Accessed July 21, 2011.
2 Reinhardt UE. Fees, volume and spending at Medicare. New York Times Economix blog. December 24, 2010. Accessed July 21, 2011.
3 Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. High-value, cost-conscious health care: Concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011;154:174–180.
4 Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181–189.
© 2011 Association of American Medical Colleges