The document discusses the need for cost consciousness in medical training and practice. It identifies controlling healthcare costs as a primary challenge this decade. Current efforts are outlined to educate trainees and clinicians about high value care and reducing overuse of diagnostic tests. While competencies require awareness of costs, most residents report receiving little feedback or education on utilizing resources efficiently. The document calls for strengthening training programs to ensure cost-consciousness becomes a core value for physicians in practice.

1. Addressing This Decade's Primary
Challenge for Medical Training
Patrick C Alguire, MD, FACP
Senior Vice President, Education
American College of Physicians

2. Overview
 Why is cost consciousness
important?
 Examples of current efforts to
control cost
 What is the current status of cost
consciousness during training?
 What might/should be done?

3. Overriding Issues in
Health Care
 Issue of the decade starting in
2000: quality of care and patient
safety
 Issue of the decade starting in
2010: decreasing the cost of
care

4. Cost of Health Care
CMS, Office of the Actuary, National Health Statistics Group

5. Excess Cost Domain Estimates
IOM. The Healthcare Imperative, 2010.

6. Why are Diagnostic Tests Overused
and Misused?
 Lack of guidance  Insecurity about
or guidelines clinical skills
 Lack of knowledge  Discontinuity of
 Patient care
expectations  Fear of
 Inadequate time malpractice
 Discomfort with  Habit
uncertainty  Personal gain

7. Overview of Goals for the ACP
HVC Initiative
 Develop guidance for physicians
about appropriate use of care,
focusing initially on diagnostic testing
• Assemble and integrate evidence-based
and consensus-based recommendations
 Educate target audiences about areas
of overuse and misuse of care:
• Practicing clinicians
• Trainees (students, residents, fellows)
• Patients

8. Ann Intern Med. 2011; 154:174-180

9. Identifies 37 clinical situations in which a
screening or diagnostic test does not reflect high
value care.
Ann Intern Med. 2012; 156:147-149.

10. Other National Initiatives
 National Physicians Alliance:
“Top 5” Campaign
 ABIM Foundation: “Choosing
Wisely” Campaign
 JAMA Internal Medicine (Arch
Intern Med): “Less is More”
series

11. Choosing Wisely® Partners
 ABIM Foundation (convener)
 American Academy of Allergy, Asthma &
Immunology
 American Academy of Family Physicians
 American College of Cardiology
 American College of Physicians
 American College of Radiology
 American Gastroenterological Association
 American Society of Clinical Oncology
 American Society of Nephrology
 American Society of Nuclear Cardiology
 Consumer Reports

12. What are the current program
requirements re cost-consciousness?
Under:
IV.F.5.f) Systems-based Practice
Residents are expected to:
IV.A.5.f).(3) incorporate considerations
of cost awareness and risk-benefit
analysis in patient and/or population-
based care as appropriate

13. Are We Educating Residents?
(From University of Pennsylvania)
 37% of residents were provided some
feedback about their resource utilization;
20% reported receiving feedback regularly
 16% developed a concrete plan with their
attending physician for improving
resource utilization; 28% reported
receiving any corrective feedback
 63% reported having no idea about cost of
tests
Source: JGME. 2010; 2:175

14. A Resident’s Perspective on Top 10
Reasons for Over-Ordering
1. How we’re taught 6. Broader ignorance
(don’t consider cost) (costs are opaque)
2. Trying to do our best 7. Not realizing how
for the patient much setting affects
costs (e.g., ER)
3. Pre-emptive ordering
8. Defensive medicine
4. Covering all bases
(more=better) 9. Patient requests
5. General lack of 10. Lack of oversight
awareness (of cost)
Neel Shah. CommonHealth.wbur.org

15. Coming Your Way Soon!
 ACGME is increasingly concerned about
overuse/misuse of care
• How to strengthen current competencies to make programs
accountable
 ABIM is becoming more focused on stewardship
of resources
• More Items in the certifying and MOC examinations
 IM-ITE contains “high value care” subscore

16. Cost-Consciousness and
Training
 Habits start early in training →
need to focus on students,
residents, and fellows
 Joint initiative to develop HVCCC
program for residents: AAIM
and ACP

17. Ann Intern Med. 2012; 157:284-286.

18. Curriculum Dissemination and
Evaluation
 Over 5200 individuals have accessed the
curriculum to date
 Approximately 16% of those accessing
the curriculum are residents and students
 Plan for feedback survey about the
curriculum
 Other metrics: resident survey; program
director’s survey; high value care sub-
score on the IM ITE

19. Challenge for Program
Directors
 Focus on cost reduction and
minimizing overuse/misuse of
diagnostic testing
 Questions
• Why did you order that test?
• Was it the most appropriate and cost-
effective test to order?
• What are you going to do with the results?
• Will it change your management?”

20. The Bottom Line
 Health care costs are unsustainable
 Nearly 1/3 of health care costs are wasted
 Physicians have control over a significant
component of these wasted costs
 Current physician practice and training
have not focused on avoiding waste
 The culture of training must change to
assure cost-consciousness and avoiding
waste becomes a core value that
residents understand and practice