A dozen second-year medical students were gathered around a hospital seminar table, and I was their preceptor. They had been asked to work up cases to present to the group, not simply to discuss clinical options, but to do something rarely required so early in medical education: to weigh the benefits of those options against their costs. A female student brought up the case of a patient with Henoch-Schöenlein purpura whom she had seen during a previous rotation in another hospital. She asked a question that went to the heart of the matter.
"Why is this patient even in the hospital?" she said.
She jumped to the head of the class.
It should be a source of some satisfaction, however abstractly, for physicians who deal today with capitation, precertification, closed panels, utilization review and the other manifestations of a cost-conscious era to know that considerations of cost have reached the previously sacrosanct halls of medical school. In 1994, while I was associate vice chancellor for health affairs at Duke University Medical Center in Durham, N.C., Duke became the first medical school in the nation to introduce a required rotation in cost-effectiveness into the medical curriculum.
The rotation was the brainchild of Dan Blazer, M.D., Duke's dean of medical education. A psychiatrist, Blazer made the innovation possible by yielding two weeks' time from the psychiatry rotation — precious "turf" by the usual reckoning of academic departments — because he believed students should be prepared to practice medicine in the real world. As such topics are more fully integrated into the general curriculum, the formal rotation at Duke may be phased out while the principles behind it remain. But the two weeks proved an interesting exercise in learning, for the faculty as well as the students — not least because of that student with the Henoch-Schöen-lein purpura patient.
What made the student's argument impressive was not that she was necessarily correct — although it certainly seemed to me and to the rest of us that she made a persuasive case that the patient with this clearly diagnosed problem did not require hospitalization. And the point isn't to pass judgment on the physician or physicians, unknown to me, who made the original admission decision for that patient at a different institution. I'm well aware that hindsight can be a wonderful advantage in such instances.
The point is that, right or wrong, the young medical student posed the question she did. The case, after all, had not been assigned to her with the question, "Did this patient need to be admitted?" The student went beyond the confines of the review expected of her to question a key assumption. That's exactly the kind of thinking that will be necessary to rein in the costs of American health care while preserving and enhancing its quality.
What we have found is that students can learn to evaluate questions of medical cost-effectiveness, even in the second year of medical school. But some of these concepts can be introduced too early; late second-year students did better than early second-year students in handling these issues, for example. We concluded that a certain basic grounding is necessary about what tests can tell us and what procedures can achieve before students can make knowledgeable choices about the cost-effectiveness of those tests and procedures. Nonetheless, we can begin a general background early in their education.
It may need to be stressed that when we invite students to study cost-effectiveness, we mean both parts of that hyphenated compound word; we truly wish to examine the effectiveness of care as well as its cost. We like to say that cost-effectiveness is an expression that has a numerator and a denominator.
In some cases, there will be easy calls to make. A large multi-center trial, for example, demonstrated that using class 1C agents to treat asymptomatic premature ventricular contractions may do more harm than good on balance, never mind the cost. Forgoing such treatments is an easy call. And the randomized clinical trials we're now seeing in increasing numbers are showing us more instances in which our conventional view of what is good for patients has been challenged.
There are cases where the more effective of two tests or treatments is also cheaper, or is equal in price. And there are cases where two tests or treatments are equally effective, but one is cheaper. These, too, are easy calls.
Of course, there are also tougher calls. Another study has shown that using the thrombolytic agent TPA instead of the less expensive streptokinase can reduce mortality by about 1 percent. I know of one health plan that urges the choice of one because it's better, and another plan that suggests the other because it's cheaper. Given that the ethics of population-based medicine assumes that resources spared in the treatment of one patient will be available to treat another, I don't pretend that that is an easy choice to make.
A rule to remember
In preparing medical students to face more difficult choices like these, I think it's important to set a basic ground rule: "Tough call" decisions where cost and effectiveness diverge should be made on the policy-setting level; they should not be left to be made at the patient's bedside. There, an individual physician must remain indivisibly and unqualifiedly an advocate for his or her particular patient. Furthermore, any mechanism that denies treatment options through protocols, guidelines or rules of any kind should offer an appeals process for the "unusual" patient.
Are medical students who have been exposed to instruction in cost-effectiveness taking it in stride or exhibiting stress over it? I have been asked this either-or question, and my answer to it is "yes." I don't mean to be inscrutable. Medical students are learning these concepts, and they are creating appropriate stress for them, just as they create stress for all of us. When cost considerations point one way and effectiveness considerations the other, there is no simple formula for making a moral and practical choice.
Such decisions must be faced, and the upcoming generation of physicians must be prepared to face them. That's why programs such as the cost-effectiveness rotation at Duke — and the staged introduction of cost-effectiveness principles under way now at Baylor College of Medicine in Houston, where I have a new position — are blazing a necessary trail in medical education.