“What’s the next step?” asked my econometrics professor as I handed in my last undergraduate exam.
“Medical school,” I said.
He chuckled. “Good luck. Health care is in a rough spot.”
An economics background provides a unique perspective on medicine. Economics and medicine have similar education models. The initial coursework introduces the vocabulary and principles of the field to develop a base of knowledge. The subsequent coursework integrates these concepts to approach more complex problems. However, the field of economics is less rooted in teaching a defined and structured curriculum. Rather, it focuses on developing a style of thinking to see how interplay of economics principles can be applied to the decision-making process.
Anatomy, biochemistry, histology and physiology build the foundation of medical education. The interplay between supply-demand curves, incentive structure, cost-benefit analysis and externality studies forms the core of economics education. Upon graduation, I left with an understanding of economics that I did not expect to significantly apply to my pursuits in medicine. At the time, I was unaware these concepts would be at the heart of a growing initiative in the health care system that hopes to integrate high-value care into the way physicians and students practice medicine.
The health care system steadily faces increasing costs. Under its current trajectory, health care spending is projected to account for nearly 20% (approximately 5.5 trillion dollars) of the U.S. GDP. $700 billion of this money is considered avoidable and unnecessary, including $325 billion of unwarranted use, $100 billion of provider inefficiency, and $50 billion of poor care coordination. While unfortunately there is no silver bullet for this challenge, the health care system must attempt to reduce costs without compromising the quality of patient care. Without an unexpected new revenue source on the horizon, many health care leaders have started prioritizing high-value care to address this issue. The concept is straightforward: for each dollar spent, health care teams are to focus on achieving the greatest health outcome. However, the challenge lies in developing this mindset in today’s health care professionals and medical students.
Before implementing its High Value Care Training, a needs assessment conducted in the UNC Department of Pediatrics found that a majority of the teaching faculty and residents did not feel confident in their abilities to deliver high-value care and few had received any relevant instruction in the past. In the hopes of delivering change, the department used case-based learning and guided lectures in a five-part series to teach high-value care through an understanding of its benefits and harms, decreasing low benefit interventions and choosing high benefit interventions, customizing care according to patient values, and identifying system-level opportunities to improve outcomes.
While the training guided physicians through numerous “real-life” scenarios, participants admitted there would be challenges towards clinical implementation. They most frequently expressed difficulty changing habits, limited knowledge about cost and a lack of support and instruction from administration. While helpful, these trainings do not remove structural barriers that prevent physicians from implementing this style of approach to medicine immediately.
Giving consideration to this feedback, the evidence points to the importance of introducing value based health care training early on in medical education. In 2012, the AAMC adopted the Do No Harm Project out of the University of Colorado. This initiative seeks to develop clinical vignettes written by physicians to humanize concepts of medical overuse, overdiagnosis, and downstream harms and challenge the “more health care is better” culture. Through focused case studies, this program seeks to expose students to cost-based thinking starting in their classroom education.
This conversation, however, is not one-sided. The Department of Ethics at the Johns Hopkins University agrees with the clear need to reduce costs but expresses concern towards accomplishing this without compromising the quality of patient care. Ideally, Hopkins suggests putting greater emphasis on teaching students to communicate the costs of health care initially while introducing more complex concepts of value later on in training. They encourage teaching cost-wise care without sacrificing its quality. This hopefully ensures a distinction that high-value care is not the same as low-cost care.
I understand the long-term benefit of introducing students to high-value care early in training, but I share the ethical concerns mentioned above. Ultimately, physicians are asked to uphold the Hippocratic Oath and care for patients. Medical education is fast-paced and high-volume, with the goal of ensuring that students meet a set of academic competencies. In its current structure, medical education often leaves insufficient time to properly introduce and teach important concepts, such as high-value care. While vignettes and seminars can teach high-value care in theory, it is a greater challenge to expect students to seamlessly integrate potentially new concepts into a clinical mindset without long-term exposure and comfort with high-value care.
Considering the challenges and shortcomings associated with a condensed curriculum of high-value care, I suggest a two-part method to introduce students to this style of thinking in a meaningful manner earlier in their medical careers. The end goal is to expose students to the financial aspects of medicine through a longitudinal curriculum during their preclinical years: specifically, showing how each step of a hospitalization including tests, orders and medications sums towards the final cost of health care and peeling back the curtain to show how the conversion of health care services into health care costs allows students to incorporate the concept of cost into their clinical mindsets before they hold direct patient care responsibilities. Teaching basic sciences and fundamentals is essential to quality care but understanding the interplay between medicine and the health care system will better prepare students to thrive in the hospital setting later in their careers.
While this idea requires greater structural change, an immediate option for medical schools to consider is requiring economics as a prerequisite for admission. Introductory chemistry, biology and physics courses are already required to ensure students have a cursory knowledge of basic science so medical education can immediately launch into higher level discussions. If high-value care is one of the primary initiatives in medicine, then requiring incoming students to be familiar with cursory economics may be just as efficacious towards accomplishing this goal. Rather than using valuable course time to teach rudimentary economics issues, leaders in health care can engage students in decision-making strategies and economically sound approaches to medical management. Introducing these conversations earlier in medical education will allow students to more easily begin practicing medicine with value in mind rather than implementing such a mindset later in their careers.
With health care spending becoming an increasingly important topic, medical schools will have to find a way to integrate the fundamentals of high-value care earlier in the curriculum. Students should be familiar core economic principles and how they apply to health care before they are treating patients. However, this new focus in health care should not ignore the patient’s well-being at the risk of these economics principles. Schools must find a way to incorporate these overlapping values seamlessly and they must do so quickly.