Opinion articles

Thursday, May 3, 2012

The Morality of Resource Stewardship


BY Rob Schreiner, MD, FACP, FCCP

Executive Medical Director

Kaiser Permanente of Georgia

President-Elect, Medical Association of Atlanta


Many of us rightly feel pride in being good stewards of life’s resources. We feel a moral responsibility to reduce, reuse, recycle -- to get by with only what we need. Do you feel that same pride of stewardship when delivering optimal care for a member, using only the healthcare resources needed to achieve an excellent result?  Asked another way, do you believe we have an ethical responsibility to reduce waste in health care?


The Morality of Environmental Stewardship

It’s Wednesday morning in my cul-de-sac. My overflowing blue bin and blue bag are clear evidence of my commitment to being a good steward of Earth’s resources. It also feeds my competitive spirit -- I’m recycling more this week than my neighbor Andy (Ha!), but not as much as my friend Bryan (Damn!). 


Since DeKalb County began its curbside recycling program, my weekly “contributions” to the landfill have fallen by at least 50%, probably 65%.  I take great pride in that. You may be doing even more -- driving a Toyota Prius, exclusively using CFL bulbs, setting your thermostat to 75°F during the summer.  Whatever steps you and I are taking, we agree it’s ethically sound, maybe even morally superior, to conserve environmental resources.


The Morality of Household Stewardship

You shopped until you dropped, comparing prices across countless physical and digital stores.  You clipped coupons or drove an extra 20 miles to save $5 (don’t do the math, it will discourage you). You make the most of your leftovers (even though most of us throw away food that 4 billion hungry humans would have considered more than edible -- a “sin” when I was growing up).  Again, we can agree that we feel proud when we conserve household resources.


The Morality of Healthcare Stewardship

A patient presents with a common complaint -- one that our years of training and experience tell us can be diagnosed simply and treated reliably -- yet he asks for the same battery of tests that their neighbor received from their physician.  He believes that “more” healthcare is necessarily better. 


Most clinicians I speak to in Georgia, particularly outside of TSPMG [The Southeast Permanente Medical Group], don’t feel it’s their responsibility to manage quantity or cost of healthcare resources consumed in the course of caring for a single patient.  We justify our spending behavior in a myriad of ways … 

         (1)  the ambiguity of clinical circumstances,      

         (2)  having insufficient time to think (the waiting room is full, after all),

         (3)  the patient insisted upon the additional testing,

         (4)  we (falsely) believe more testing will protect us from allegations of medical malpractice,    

         (5)  the cost of healthcare is someone else’s problem (hospitals, pharmaceutical companies, health plans, etc.), or

         (6)  we want to be seen by the family as “doing everything medically possible” to achieve an improbable outcome.  Not many clinicians these days feel pride in achieving an optimal clinical outcome while spending only the necessary resources to achieve that result.  We don’t feel the same ethical twinge we get when we toss an aluminum can in the garbage instead of the recycling bin.


It wasn’t always that way.  During Morning Report at Vanderbilt in the mid-1980s, I recall having to justify every test ordered for every patient admitted. The ethic was something like this … only the best and brightest docs figure out the diagnosis fastest, implement treatment quickest, and ensure that treatment is effective for that individual patient.


The process was powered by incisive clinical acumen and an intense reverence for medical reasoning.  Clearly, those docs who made the correct diagnosis most rapidly, who subjected their patients to (only) the confirmatory test(s), were superior.  It was our duty to practice efficient medicine. 


Well, that ethic is making a comeback.  A coalition calling itself Choosing Wisely (http://choosingwisely.org/) recently released a list of 45 tests and treatments that physicians should no longer automatically order. Dr. Christine Cassel, president of the American Board of Internal Medicine (ABIM), says the goal is to reduce wasteful spending.


"We all know there is overuse and waste in the system, so let's have the doctors take responsibility for that and look at the things that are overused. We're doing this because we think we don't need to ration health care if we get rid of waste."


When we practice good Resource Stewardship, patients benefit. Consider this sentence from a recent JAMA editorial ... "Because responsible management of medical resources benefits patients individually and collectively, it should now be considered a central professional responsibility (Brett AS, McCullough LB, JAMA 2012[307]:149-150)." 


It’s not easy to address requests by patients for nonbeneficial interventions, but by hearing a patient's root-cause concerns, using excellent communication skills, and engaging in shared decision making, you can create excellent quality, low-waste health care that is deeply satisfying to both patient and clinician.


I’m thrilled with our Resource Stewardship Program.  It’s borne from the belief that we clinicians have a moral and ethical obligation to eliminate waste and practice with incisive clinical acumen.  All we need is a little data on best-practices coupled with collegial pride and mentoring to guide us toward more efficient, effective healthcare.


Published originally in Kaiser Permanente's 'The Five in Five' series, reprinted with permission