Views & Reviews Personal View

Doctors should be taught to consider the cost of their practice

BMJ 2014; 348 doi: (Published 16 April 2014) Cite this as: BMJ 2014;348:g2629
  1. Bela Nand, medical director care management and associate program director, Internal Medicine Residency Program, Advocate Christ Medical Center, Illinois, Oak Lawn, IL 60453, USA
  1. belanand{at}

Good clinical practice should include consideration of how to distribute scarce healthcare resources, writes Bela Nand

Almost a century ago, Abraham Flexner, a research scholar at the independent think tank the Carnegie Foundation for the Advancement of Teaching, undertook an assessment of medical education in North America. His 1910 report was the impetus for changing American medical education, transforming healthcare delivery.1

Today, however, many US junior doctors’ residency programmes are “not well aligned with objectives of delivery system reform.” So concluded the Medicare Payment Advisory Commission when in 2009 it reported data from a study by the RAND Corporation, the non-profit making think tank.2 Specific concerns included a lack of formal instruction in multidisciplinary teamwork; a lack of comprehensive health information technology; a lack of patient care in ambulatory settings—and a lack of cost awareness in clinical decision making.

Many clinicians argue that at no point, no matter the economic environment, should cost be a factor in physicians’ decisions. Art Caplan, a bioethicist at New York University, frames the dilemma in terms of advocacy rather than cost: can a physician remain a patient advocate while serving as a steward of society’s resources?3

Good clinical medicine should incorporate the four principals of ethical medicine, one of which is justice, in regard to how scarce health resources are distributed. But this is often overlooked.4

Economists project that in the United States by 2020 spending on healthcare will reach 19.8% of the gross national product. By some estimates, nearly one third of those expenditures will be for unnecessary services. That could amount to as much as $765bn (£456bn; €552bn) of avoidable costs.5

It is time to introduce the terms “value based purchasing” and “pay for performance” to the vocabulary of the medical education curriculum. Many physicians’ organizations are moving in this direction, most recently with the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.6 7

A medical curriculum is being developed jointly by the American College of Physicians (ACP) and the Alliance for Academic Internal Medicine (AAIM). It targets internal medicine residents and provides them with knowledge, training, and insight into “cost consciousness.”5 The curriculum sends an important message to residents that, contrary to current beliefs, it is acceptable to mention cost in the same breath as treatment when discussing care plans with their patients. After all, isn’t involving the patient in all aspects of their care, whether medical or financial, a form of patient centered care? To implement this curriculum will take staff who are skilled in holding difficult conversations with patients and families in an effective, honest, and compassionate manner.

Well managed team based care results in lower rates of emergency room, clinic, and hospital days—services financed largely by Medicare. The American Board of Internal Medicine (ABIM) recognizes the importance of care coordination and has recently implemented a performance improvement module.

The University of Louisville School of Medicine surveyed residents and fellows to explore their perceptions and knowledge of issues related to healthcare business and healthcare reform. It concluded that residents were aware of their knowledge gaps, and the school used the findings of that survey to inform its curriculum and delivery.8

We took a similar approach at our institution, Advocate Christ Medical Center, Illinois. We started a “patient safety/quality” rotation with the goal of introducing care coordination to our internal medicine residents. Residents are eager to learn; we as educators have to be more creative and find innovative means to share this knowledge with them.

An article in JAMA 15 years ago compared the cost per case in teaching hospitals with non-teaching hospitals.9 The authors concluded that the cost of teaching hospitals was vastly inflated relative to their non-teaching counterparts. The total estimated cost of US graduate medical education was between $18.1bn and $22.8bn in 1997.9 The authors raised an interesting question: does the US medical education system meet the country’s needs? This question is even more pertinent today than it was a decade ago.

Healthcare expenditure has increased from $253bn in 1980 to a staggering $2.6 trillion in 2010. About 30%, more than $700bn annually, is spent on care that is potentially avoidable and would not negatively impact the quality of care if eliminated: so called “wasted care.”10

Some educational leaders are pushing the Accreditation Council for Graduate Medical Education (ACGME) to consider introducing cost consciousness as the seventh core competency.11 I however think that cost consciousness is already part of the core competencies so revered by the ACGME. Systems based practice is well defined by the ACGME. Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of healthcare as well as the ability to call on system resources to provide care that is of optimal value.

More care does not necessarily translate into better care. The mindset of ordering myriad costly tests could be changed with simple questions. How is this test going to benefit my patient? How is it going to modify the treatment? What am I going to do with the results?

Medical educators are in a unique position to influence and prepare not only our next generation of excellent clinicians but also excellent healthcare stewards. To change the future we have to invest in the present, and teaching doctors cost consciousness early in their career would pay dividends.


Cite this as: BMJ 2014;348:g2629


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.