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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 …

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