Healthcare costs are the new “elephant in the room” and providing cost-conscious care should be the seventh general competency for physicians, according to an editorial appearing in the Sept. 20 issue of the Annals of Internal Medicine. The approach includes reducing unnecessary imaging studies to help cut the estimated $700 billion in wasted healthcare spending annually.

Steven E. Weinberger, MD, of the American College of Physicians in Philadelphia, wrote that it is the responsibility of the medical profession, not just the government, to become cost-conscious. One of the primary ways to reduce costs would be to decrease unnecessary care that doesn’t benefit the patient.

“I was prompted to write the editorial because I believe (as does the American College of Physicians) that it is the professional responsibility of physicians to do what we can to reduce the actual cost of care by eliminating (or reducing as much as possible) diagnostic tests and treatments that do not help patients, but only add to the cost of care,” Weinberger said in an interview.

Weinberger said that, in many cases, physicians don't think about the value of the testing they order, whether there’s a less expensive, but equally useful test or whether the information will really affect the care of the patient.

In imaging, for example, Weinberger said MR and CT scans are overused for evaluation of uncomplicated lower back pain. He also said chest CT scans are overused in circumstances when a plain chest radiograph is sufficient, and CT angiograms are overused to rule out pulmonary embolism in situations when the pre-test clinical probability, as determined by clinical prediction scores, is low.

For Weinberger, the ability to control costs is so important it should be added as a seventh general competency for physicians to acquire during training.

About a decade ago, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties defined six general competencies that were critical for a physician to acquire during training. These were:

• Medical knowledge;

• Patient care;
• Professionalism;
• Interpersonal and communication skills;
• Practice-based learning and improvement; and
• Systems-based practice.

Currently, residents are expected to factor in cost awareness as part of the systems-based practice competency, but Weinberger doubts the sufficiency of this approach. Efforts to teach cost-effective care or prompt it through audits have not been successful.

“The practice habits that are developed during medical school, residency and fellowship training often persist throughout a career,” wrote Weinberger. “After one finishes training, the opportunities to be influenced by respected role models decrease considerably, thus making the habits of practicing clinicians particularly difficult to break. On the basis of experience with interventions used in the training environment, however, it is clear that new methods must be tried.”

Weinberger noted that waste in the healthcare system is a major factor in overall cost, with more than $700 billion estimated to be wasted per year.

Weinberger pointed out that the per capita volume of imaging and other diagnostic tests for Medicare beneficiaries has increased approximately 85 percent in the past decade.

“We don’t know what percentage of the increase was due to excessive imaging, but it is certainly a striking increase in the number of studies,” noted Weinberger.

The editorialist acknowledged that changing the culture in training programs won’t be easy, but that it could be achieved with a concerted effort by certifying and accrediting bodies that mandate cost-consciousness as an important part of training for future physicians.