The triage nurse approached Jan, a rotating intern, with a request to order a head CT scan on a middle-aged woman who had a headache and was vomiting. (All identifying details have been changed.) This was Jan’s second week in the emergency department, and she wanted to be cooperative with the triage nurse and also to not miss any serious emergencies, like a stroke or bleeding in the brain, that could cause the patient’s headache. She knew that timely diagnosis could avert some of the complications of a stroke or brain hemorrhage. Jan saw no reason to disagree with the nurse’s suggestion and was putting the order into the computer when I happened to sit down next to her while working on another patient’s chart. She described the case to me, and I asked her to hold off on ordering the CT scan until we could speak with the patient and examine her together. A few minutes later we greeted the woman, who was in a dark room, crying and vomiting. Light hurt her eyes and made the headache worse. The woman was clearly in pain, and I could understand why the triage nurse was concerned. But as we spoke with the patient, we learned that she had a history of migraine headaches and that this particular headache, while worse than most previous ones, was also very similar to her usual migraines. We examined her carefully and found no neurological abnormalities. Instead of ordering the CT scan, I suggested that we administer an antimigraine medication. Within 20 minutes the woman was resting comfortably and we were able to carefully examine her, review her history, and discharge her to go home an hour later without the CT scan or any other tests.
When the patient had left, Jan and I discussed the challenges of limiting tests when there was uncertainty about a diagnosis, particularly one that might be very serious, like a stroke. How was the triage nurse or an inexperienced intern to know, without a CT scan or other tests, which headaches were serious? The consequences of missing a stroke would be grave for the patient and could lead to liability for the physician. A history and physical exam were not completely reliable for making a diagnosis. While there are articles in the medical literature that could guide testing and treatment decisions based on history and physical exam findings, most suggest that if the suspicion is high, imaging studies such as the CT scan could rule out the most serious conditions.
Jan confided that she had a high suspicion about almost any headache that would bring a patient to the emergency department. She believed that only experienced physicians might be willing to trust their clinical judgment to make a diagnosis of migraine headache when a patient was crying in pain. As an intern, her experience was limited, and she depended on the nurses and on online resources that tended to emphasize ruling out the higher-risk conditions like stroke. Unfortunately, the decision to obtain the CT scan would add thousands of dollars to the emergency department charges, which would be paid for either by the patient, her insurance, or some government program like Medicare or Medicaid. These programs are struggling with how to contain rising health care costs, and physicians’ decisions about tests and treatments are major contributors to the costs. This challenge led us to briefly consider the problem of the high cost of health care and how medical education might be able to help reduce it.
High health care costs are of concern not only to the patient—who often has to pay part or all of the bill, like our patient with the migraine headache—but also to anyone who pays a premium for health insurance or taxes to the government, which finances Medicare and Medicaid. Health care is increasingly absorbing financial resources that are needed for other essentials, such as construction of roads, support of schools, and national defense. Financial pressures from the health care needs of an aging population are causing a shift in the priorities of health reform from covering our population with health insurance to reducing the cost of health care while maintaining or improving quality. While the amount of health care spending varies from country to country, in 2014 the United States led all countries in per capita spending at $9,255 per capita, or 17.4% of GDP.1 However, other countries are also experiencing increases in health care spending,2 largely driven by the growing populations of the elderly, who have greater needs for health care. Older populations have a greater burden of chronic diseases than younger populations, and the number of chronic diseases is associated with higher health care spending.3,4
There is general agreement that health care spending must be controlled, and most solutions have involved changes in the incentives for health care spending through payment reforms that move physicians away from a fee-for-service reimbursement system to alternative payment systems such as bundled payments or prospective population-based payments.5 The rationale for this approach is that fee-for-service payments encourage physicians to do more procedures, tests, or treatments than might be necessary and that alternative payment approaches, such as those mentioned above, might cause physicians to adopt more cost-effective approaches. The Secretary of Health and Human Services, Sylvia Burwell,6 recently expressed the goal of moving physicians from fee-for-service payments to alternative payments for 50% of Medicare beneficiaries by 2018. The problem of overtesting and overtreatment affects both government-sponsored health care programs and private ones. Porter7 suggests that the problem can be addressed by moving from volume to value, with the idea that value in health care should encompass improvements in quality and reductions in cost.
Since physicians are responsible for a substantial amount of health care spending decisions, the movement of physicians into alternative payment systems could have great impact on overall health care spending if the payment changes would provide incentives for physicians to reduce spending. Whether currently proposed changes in payment incentives, based on rewards to individual physicians and penalties related to quality and efficiency, will result in the needed reductions in overall health care spending is not clear.5
Medical education is rarely mentioned as a way to promote the goals of payment reform or as a separate solution to the problem of increased health care spending. In the rest of this editorial I will suggest that there are many opportunities to use our medical education system to decrease health care spending and improve quality. Some of these opportunities are related to new payment incentives, and some are independent of them.
I believe that the reason medical education has not been considered as part of the solution to the current crisis in health care spending may be because educational activity has traditionally been separated from clinical practice, both in time and location. The first two years of medical education typically occur in classrooms away from the hospital, and the later clinical rotations stress pathophysiology, clinical decision making, or procedural expertise. Educators do not typically participate in making meaningful changes and improvements in clinical processes. However, behavior change directed at health care spending by physicians could be integrated into medical education by developing care delivery innovations that incorporate educational principles and methods.
The use of medical education as a driver for change could be supported by learning theories such as social cognitive learning, situated learning, and experiential learning, in which education is intimately tied to group values and goals. In social cognitive theory, individual learning—a form of personal agency—“operates within a broad network of sociostructural influences…. [These involve] socially coordinative interdependent efforts.”8 In situated learning, described by Lave and Wenger,9 learners participate in real-world experience and undergo a socialization process that provides the context for understanding and applying the knowledge they gain. In Kolb’s experiential learning theory,10 a cycle of learning occurs based on experience, reflection, abstraction, and testing of new ideas with further experience, with the goal of continued creation of knowledge through experience. Applying these learning theories to change physicians’ behavior could create a synergy of learning theories with current quality improvement efforts in medicine. These theories suggest that education can be integrated into changes in the process and structure of medical care, helping doctors develop new skills and knowledge while changing the care delivery environment in an iterative and self-reinforcing cycle. For example, when I was able to point out the key findings that would differentiate a patient with migraine from one with a stroke, that increased the knowledge of the intern and triage nurse, who would then adjust their approaches for ordering a CT scan for future headache patients. Using education to reduce unnecessary testing is one way to increase value in our health care system and could have important implications for reducing health care spending.
Berwick and Hackbarth11 identified various areas of waste in health care by identifying types of health care spending that do not improve value such as overtreatment, failures in care coordination, failures in execution of care processes, administrative complexity, pricing failures, fraud, and abuse. They estimated that 20% of health care expenditures might be accounted for by wasted spending. Medical education could address all of these areas but is particularly suited to address overtreatment, failures in care coordination, and failures in the execution of care processes. The Choosing Wisely program12 enlisted all specialties in medicine to identify those procedures that were often unnecessary. This was an excellent starting point in focusing on areas to change physicians’ behavior that would improve value. Unlike the use of payment incentives to change behavior, in the Choosing Wisely project, physicians did not receive incentives to participate. Rather, the motivator for broad participation of medical specialties was altruism and peer pressure to improve care. But the identification of overused tests is only the starting point. Changing behaviors is difficult, particularly when the behaviors are ingrained habits. Here is where it is critical for education to address how to make changes in behavior. Simply knowing the list of unnecessary tests does not change behavior. Just as the intern and triage nurse might know that CT scans are overused in headache patients, they would not know how to identify the patients who did not need the test. However, with education reinforced with process improvements, the behavior can be changed.
Pronovost et al13 provide an example of how education can partner with process improvement to increase value. They demonstrated in a multi-institutional study how to reduce central line infections through an intervention that combined education and process change in the intensive care unit. This project involved identification of team leaders in the participating ICUs who were trained in the science of safety and the interventions to be used. These leaders educated their colleagues and implemented the agreed-on interventions; data were collected to track performance. The incidence of central line infections dropped significantly, saving lives and reducing the expense of additional hospital days.
While organized groups with leaders could actively develop and implement integrated educational and practice improvement processes, change could also emerge spontaneously from within an organization. Leggott et al14 describe the transformation of anesthesia for orthopedic procedures from general anesthesia to peripheral nerve blocks. They describe how the process emerged spontaneously within a group of anesthesiologists and how, via education and process change, the procedure spread to the orthopedic surgeons and gained the support of all participants until peripheral nerve blocks largely replaced general anesthesia. Residents learned the procedure and helped spread it within the health care system. The introduction of nerve blocks lessened pain and vomiting afterwards and reduced hospitalization, thus being an example of an educational innovation that improved value in the health care system without any financial incentives for physicians to change behavior. Effective education and communications were key elements needed to support the adoption of this innovation. The diffusion of this innovation followed a classic pattern described by Rogers15 in agriculture.
Improvements in care can also occur in nonprocedural care management. One of the most challenging problems in health care is the management of patients with multiple chronic illnesses. Bodenheimer et al16 have identified care coordination of patients with chronic disease as an opportunity for both better quality and lower cost. Programs to achieve these goals typically involve patient and provider education linked with nurse case management and have demonstrated reductions in emergency department visits and hospitalizations for patients with chronic diseases.16 In this issue of Academic Medicine, Gupta et al17 describe site visits to 23 primary care clinics from March 2013 to May 2015 in which residents’ medical education has been integrated into the care management programs in the clinics, which emphasize continuity of care and team-based care. Residents’ schedules were adjusted so that ambulatory patient care experience was given priority in scheduling equal to that of inpatient rotations. The organizing principle for the residents’ clinics is “Good education for tomorrow’s doctors requires excellent care for today’s patients.”
Also in this issue, Wong and Holmboe18 describe how a reconceptualized approach to graduate medical education would put patient outcomes at the center of both the educational and clinical care systems. A successful education program would require a successful clinical care program, and engagement in quality improvement by residents, students, and faculty would be an integral part of the educational program. Faherty et al19 in this issue describe three options for residents’ engagement in quality improvement—short-term, medium-term, and long-term—which can accommodate a variety of settings and specialties and should make it possible for all residents to participate in meaningful quality improvement activities. Whether the quality improvement activities involve reductions in test ordering and imaging, as recommended by many of the Choosing Wisely proposals, or, instead, improvements in the discharge process—as mentioned in this issue by Wong and Holmboe18 and by Vasilevskis et al20 in their survey highlighting teaching hospitals’ efforts to reduce readmissions for heart failure—the effect would be reduced spending in our health care system with better quality of care for patients. The consistent underlying approach to achieve these goals involves education of providers about possible changes in practice, review of data on current performance, and design of process changes to improve performance with checklists, reminders, feedback, coaching, and data collection to confirm improvement, similar to the process used by Pronovost et al13 described earlier. This quality improvement cycle is fundamentally a form of educational innovation embedded in process change using data to manage change, and is consistent with the current educational theories that identify socially constructed experience and action as critical for learning.
The present emphasis on improvement in value can provide the opportunity to merge the goals of medical education and health care delivery around improvements in patient outcomes. It is time for medical educators to have a seat at the table with health system designers, health economists, and clinicians to create the high-value health care system our patients need and our country can afford.
David P. Sklar, MD
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