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Responses to the 2014 Question of the Year

Fostering Value in Clinical Practice Among Future Physicians

Time to Consider COST

Levy, Andrew E. MD; Shah, Neel T. MD, MPP; Moriates, Christopher MD; Arora, Vineet M. MD, MAPP

Author Information
doi: 10.1097/ACM.0000000000000496
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Over the past 50 years, U.S. health care expenditures have grown 5 times faster than the gross domestic product and 50 times faster than real wages.1 Although much of this spending has helped Americans become healthier, at least one third ($800 billion annually) is wasted on unnecessary care and inefficiency.2 Because of mounting scrutiny from policy makers and patients, the medical profession has recently focused attention on providing better care at a lower cost. Achieving this goal will require a comprehensive approach through the engagement of clinicians at every level of training to identify opportunities for improvement. Currently, a lack of education among physicians presents a significant barrier.

While the current system equips trainees with clinical knowledge and skills, we also must teach them to be good stewards of the health care system. For medical educators to incorporate these skills into crowded curricula, they must integrate lessons about value into existing learning opportunities. For example, daily rounds could include discussions of which tests added value to the patient’s care and which did not; morning report could include a cost estimate for the final workup. Larger ventures, such as the American College of Physicians’ High Value Care Curriculum, could further augment these efforts. However, more than just training is needed. Only a multipronged approach addressing culture, oversight, and systems change will facilitate effective physician stewardship.

By focusing on rare diseases in conferences and punishing sins of omission out of proportion to those of commission, the current training environment fosters a culture of overuse. Combating this culture, however, is not easily untangled from the ingrained physician ethos to do everything possible for our patients. We need visible faculty champions to demonstrate use cases where conserving resources is in the best interest of patients, as well as society at large. In daily practice, we need attendings to celebrate restraint3 by praising appropriate omissions—for example: “Thanks for not ordering a head CT. You did not need it for simple syncope.” Trainees can even contribute through reverse mentorship of senior physicians—for example, by modeling how a smartphone application can be used to lower a patient’s out-of-pocket medication costs. Creating a culture that supports conservation will require ambassadors at every level and resource stewardship in daily practice.

Changing culture will be easier if coupled with improved oversight of scarce resources. Similar to how infectious disease specialists require approval for use of second-line antibiotics to avoid antimicrobial resistance, clinician overseers could target resource utilization. For example, radiology approval could be required to order an expensive imaging test, a practice that would not only prevent unnecessary imaging but also teach trainees about appropriate use. Combined with regular feedback regarding personal utilization, this oversight might even generate competition among providers to deliver the best care for the lowest price.

While better oversight provides personalized feedback to trainees, rethinking the system in which we practice can make better decision making routine. An oft-cited example is harnessing the electronic health record (EHR). Embedding point-of-care price estimates and best practice alerts into an EHR can enhance efficiency and education. If used ineffectively, however, these alerts also can inhibit productivity. True systems improvement requires boosting operational efficiency and rooting out wasteful workarounds. Many residents preemptively order a test just to reserve a spot in a long queue in case their patient needs it. A better system would try to unravel why there is a long queue in the first place.

The graduate medical education system will be critical to developing value-conscious physicians. As noted by the ABIM Foundation, we need to teach trainees how, when, and why to choose wisely. But if we want to consistently make the right choices, we also have to raise the stakes by incorporating value-based judgments into high-stakes training exams and rewarding high-value performance. Most important, by promoting a supportive Culture, effective Oversight, and efficient Systems of practice in concert with value-based Training, we can prepare trainees for practice in new systems of care delivery. We believe this COST framework can guide today’s medical educators as they inspire and enable the next generation of physicians to preserve our health care system.

Acknowledgments: The authors wish to acknowledge Lisa Spampinato for her help with manuscript submission.


1. Bradford JW, Knott DG, Levine EH, Zemmel RW Accounting for the Cost of US Health Care: Pre-Reform Trends and the Impact of the Recession. 2011 Washington, DC McKinsey Center for U.S. Health System Reform
2. Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. 2010 Washington, DC National Academies Press
3. Detsky AS, Verma AA. A new model for medical education: Celebrating restraint. JAMA. 2012;308:1329–1330
© 2014 by the Association of American Medical Colleges