High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.
The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.
I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco
“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.
Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”
As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.
“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”
It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”
Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.
Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.
Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?
More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver