In the United States, the cost of health care has captured the nation’s attention and for good reason; over the last 5 decades, health care spending as a percentage of gross domestic product has more than doubled, while per capita health care spending has increased nearly fivefold.1–3 While there are numerous factors driving these trends, the physician is the one key stakeholder in the health care sphere uniquely positioned to influence both the cost of patient care and the decisions of patients themselves. Indeed, the financial impact of physician decisions has been increasingly scrutinized, with some labeling the physician’s pen the most expensive technology in today’s health system.4 As physicians have rightly been moving to acknowledge the role of their contributions to increased costs,5 a new focus on high-value care (HVC) has emerged, with value defined as the health outcomes achieved per dollar spent.6
Current Educational Landscape
Despite an increasing focus on HVC, incorporating it into formal medical training has been a slow and heterogeneous process. A 2015 survey of 295 internal medicine residency directors showed that only 14.9% of programs had a formal curriculum in cost-conscious care, and fewer than one-third agreed that their residents had access to information on the costs of tests and procedures they order.7 From the resident perspective, a separate 2015 survey of internal medicine residents found that only 26.3% reported knowing where to find estimated costs of the tests and treatments they ordered, and fewer than half incorporated the costs of these interventions into clinical practice.7–9 These studies suggest that both trainees and educators acknowledge that young physicians may be exiting their residencies undereducated on the cost and relative value of the care they order. Of note, the Association of American Medical Colleges (AAMC) has published guidelines of 13 entrustable professional activities that medical students should be able to perform upon entering residency, one of which focuses on choosing and ordering diagnostic tests.10 The accompanying explanation includes an expectation that the new resident be able to “incorporate cost awareness and principles of cost-effectiveness and pretest/posttest probability in developing diagnostic plans,”10 indicating a clear need for HVC training during medical school if new residents are to be able to fulfill these expectations. In our own experience on the wards, residents hailing from a wide variety of medical schools have often confessed relative or total ignorance regarding the cost of care they provide; furthermore, residents are also unsure about how to access this information, reflecting a gap of both knowledge and skill that the AAMC has envisioned being filled in medical school.
Much of the current literature reflects a focus on implementing HVC education at the postgraduate level, and there is a lack of data on the number of medical schools with formal HVC education. The ability to provide HVC is not included in the Liaison Committee on Medical Education (LCME) standards for medical school accreditation, although other competencies distinct from but complementary to clinical knowledge, such as medical ethics and cultural competence, have indeed been adopted.11 Generally, there appears to be a disconnect between the medical community’s acknowledgment that HVC education is important and necessary and its implementation in teaching institutions across the country.12,13 As medical students ourselves, we are acutely aware of the sheer volume of medical knowledge inherent to the first 4 years of training and the corresponding opportunity cost of introducing any new component into the curriculum. Yet in the context of the ongoing crisis of health care costs, we argue that HVC education must begin in medical school to truly implement a shift toward value-based care.
Role of Medical School Education
There are many unique benefits to initiating HVC education during undergraduate medical education. First, we argue that beginning HVC training during medical school allows the cost-conscious value of an intervention to be taught synergistically with its other inherent characteristics, such as indications or positive predictive value. That is, the early introduction of cost-conscious value alongside other foundational knowledge may teach the learner to recognize HVC as an integral part of patient care and to form the habit of factoring value into clinical decision making. For instance, we argue that an initial introduction to imaging modalities is strengthened by including the relative cost of each, since this difference in price can have important clinical significance. Additionally, formalized training from year 1 of medical school may help to shift the perception of HVC to a core clinical competency on which every physician should be trained rather than an elective field into which business-minded students self-select. There has been a growing recognition that a distinct culture shift will be needed for physicians to stop treating price as an unmentionable and to become comfortable with both assessing and speaking about cost and value.14,15 By taking steps to shift this mindset early in medical school, formal HVC education may also help train the next generation of physicians not to shy away from prices but to embrace cost as another piece of data in their clinical decision making.
Moreover, there are logistical components to consider as well: A new core competency of medical education can be more easily incorporated into the medical school’s curriculum than into residency program designs. As medical school provides a generalized foundation for all clinicians, medical schools’ curricula are appropriately much more standardized than are residency programs; all medical schools are accredited by the same LCME standards, while residency programs are accredited by 29 separate Accreditation Council for Graduate Medical Education review committees and are specialty specific. Along with its 4-year duration, the breadth and variety of its subject matter ensure that the medical school’s curriculum features a rich diversity of teaching modalities into which HVC might be incorporated, while the majority of postgraduate education is on-the-job-learning with limited time for formalized didactics.
Furthermore, laying a foundational understanding of HVC in medical school allows complementary education in residency and fellowship to focus on specialty-specific HVC training. New interns with years of exposure to cost-conscious care may then enter residency equipped with a basic understanding of health care economics and reimbursement systems, allowing postgraduate HVC training to focus on more specialized knowledge. Internal medicine interns could focus on field-specific value intricacies like choice of biologic therapy, while surgical interns could study the evidence for various preoperative strategies to decrease complication rates. We believe that the same synergistic effects of integrated HVC teaching apply in both residency and fellowship but that acquiring a foundational HVC knowledge in medical school is imperative to realizing the full potential of field-specific didactics later in training.
Several medical schools have already begun including aspects of HVC in their formal curricula.16,17 We applaud their efforts and offer suggestions for further improvement. Formally identifying high-value or cost-conscious care as a core competency of a medical school’s curriculum is an ultimate goal, but in the interim, there are many smaller steps that can be taken.
Foundational lectures on the basics of health care economics and the medical reimbursement system are excellent topics for first-year didactics. During the clerkship year, rotation-specific HVC lectures allow learners to tie concepts of cost-conscious care to their current patients, such as the cost-effectiveness and preventive value of newborn screening panels while on pediatrics, or the evidence for less stringent hemoglobin A1C control in the elderly while on internal medicine. Later-year elective rotations allow for a shift to case-based HVC education, helping to prepare students to incorporate value into their clinical practice. One idea we endorse is a required fourth-year rotation with a focus on both HVC and business skills, as put forth by Pearl and Fogel18; if not mandatory, optional HVC electives in the third and fourth years should be a baseline offering of all medical schools.
Such electives, after the student has received years of HVC education, could include a self-directed project for students to speed their own institution’s progress toward incorporating HVC both as a core component of the curriculum and as a core institutional value. For example, the University of Alabama at Birmingham School of Medicine held an internal competition to eliminate low-value lab tests that made ordering necessary tests intuitive.17 Similar project-based competitions can take place at the medical school level to generate new ideas and incentivize interdisciplinary innovation. A team at the Medical College of Wisconsin has introduced a podcast-based HVC course, which educates medical students on instances of potentially unnecessary care, after which students serve as health value officers in the hospital to identify areas of care improvement and cost savings.16 A final strategy we endorse is to leverage the expertise of the medical school faculty alongside medical students’ efforts, as modeled by the University of Colorado School of Medicine’s “Do No Harm” project: Under faculty advisement, trainees write clinical vignettes to call attention to the problems they see and to illustrate the very human consequences of medical overuse.16
In recent years, our own institution has introduced several aspects of HVC training into its curriculum; for example, first-year students complete a weeklong course on the larger U.S. health care system, and clerkship students spend an afternoon seminar discussing value in health care. These offerings have provided valuable early exposure to HVC but have also highlighted the need for layering HVC training into every year of medical school to meet residency expectations of cost-conscious practice. To that end, several of us have contributed to the Choosing Wisely Students and Trainees Advocating for Resource Stewardship campaign,19 a student-led initiative to advance resource stewardship education in medical schools, and are also becoming involved with the medical center’s new HVC committee. As we approach residency, we anticipate continuing our push for formalized HVC training and look forward to helping address the challenge of designing high-yield, specialty-specific value training. We encourage interested medical students, residents, and faculty to become involved with HVC education at their own institutions; as HVC training remains a relatively recent addition to medical education, there is ample opportunity to contribute to its full integration into curricula across the country.
As current medical students, we believe we are uniquely equipped to observe the lack of emphasis that the current medical school’s curriculum places on HVC.20,21 Although early in our training, we can already identify this growing blind spot in the skills we will need for cost-conscious clinical practice. While the opportunity cost of incorporating any new competency in medical school may seem prohibitive, the integrated approach we have proposed will require a modest additional time requirement and a simple broadening of later-year elective choices. To truly reverse the trend of increasing health care costs, we must learn to incorporate value into how we think about our clinical decisions. And to change how doctors think, we must begin at the beginning: year 1 of medical school.
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