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Saturday, September 18, 2010

JAMA commentary article suggests teaching medical students to be cost conscious

This week's JAMA presents an article by Samuel Sessions MD of Harbor UCLA Medical Center and Allan Detsky of Mount Sinai Hospital in Toronto suggesting that teaching medical students to be aware of cost when learning to treat patients.  They recognize that physicians have an ethical responsibility to pay attention to the fact that medical expenditures are increasingly threatening America's economic viability and point out that training in cost-effectiveness needs to start in medical school.

A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtful and visionary authors which have informed readers. The JAMA is a free publication, at least the print edition, to physicians, and is at least partly subsidized by advertising, as are many medical publications, and its circulation is huge. I have continued to receive it since my membership has lapsed and I am grateful for that.

Today when I decided to share this article in my blog, I attempted to access it online and found that I will have to subscribe to the online version if I want to copy and paste its text into this commentary.  I'm not ridiculously cheap, but I haven't yet decided that I want to give money to the AMA. Luckily, this article has made quite an impression in various online sources, so I will quote ScienceDaily:

"The commentary is written by Samuel Y. Sessions, MD, JD, a Los Angeles Biomedical Research Institute (LA BioMed) investigator, and Allan S. Detsky, MD, PhD, Departments of Health Policy Management and Evaluation and Medicine, University of Toronto.
"New physicians will be at the hub of the health care system throughout their careers as both patient advocates and allocators of resources," the authors write in the JAMA commentary. "Instead of considering economic forces to be extraneous, medical education should develop approaches to better equip physicians for this dual role through improved teaching of evidence-based medicine that reflects both economic and statistical realities. Good patient care and good public policy demand no less."
The commentary notes that health care spending continues to grow, reaching 17.3% of gross domestic product in 2009. It points out that physicians "play a critical role not only in the well-being of their patients but also in the nation's economic welfare" as they make choices about how to care for their patients. As a result, the commentary calls for "incorporating information about economic realities into medical education to enable physicians to make better-informed decisions for patients and for the United States."
The authors point out that physicians' diagnosis, choice of medication and course of treatment can affect spending and patient well-being for years to come. To ensure economic realities are part of the physicians' decision, the authors call for a "core, required medical school course that would consolidate and integrate elements of existing health policy, ethics, and evidence-based medicine courses and modify them to better reflect overt and covert economic influences on clinical decisions."
The authors also call for revising "the remainder of medical school and residency curricula" to incorporate economic realities so that the medical students and residents would take these into consideration in their medical decision-making.
"The primary goal of incorporating economics more directly into medical education would be to improve physicians' critical capacity to assess all factors affecting their decisions, as well as their social and ethical implications," the authors write.
This is all extremely heartening.  I was especially pleased to find the article quoted so many places, because it is all well and good to have a great idea, it is something quite different to do something about it. When many people are excited, as they seem to be, momentum may build in the direction of change.  The next step in such a thing would be to have the idea attach itself to some money--perhaps a grant to medical schools that try it.  Medicare already funds a great deal of medical education and perhaps the proper direction for this to take would be for folks in the new center for Medicare innovation (part of the health care reform bill) to notice that it is a terrific idea and stipulate that medical schools receiving funding from Medicare begin to teach a comprehensive curriculum based on cost effective care.

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