In a 1,200-word story on its front page, the New York Times (4/18, A1, Pollack, Subscription Publication) reports, “Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the” US “are recommending that” physicians consider “the costs, not just the effectiveness of treatments, as they make decisions about patient care.” This “shift, little noticed outside the medical establishment but already controversial inside it, suggests that” physicians are beginning “to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.”
Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC
When I began my internship, the hospital had a talk with us about only ordering blood tests which were necessary in order to avoid excessive spending. That made an impression on me, because medical economics was something that I never heard about in med school.
But it also caused a dilemma in that we were in a teaching hospital where we might order a test because it helped with the learning process even though it might not be essential for patient care. But I think that everyone understood that the cost of care might be higher in a teaching hospital because of the learning process. That is why the government has always subsidized the training of resident physicians.
But overall, the philosophy at that institution was to teach its doctors to be conservative in everything we did from ordering medicine to choosing diagnostic tests. It wasn’t a philosophy that was primarily rooted in saving money; it was an approach to the practice of medicine which seemed sensible to me at the time, and it stuck. In the end, though, that sort of approach to medicine does lower costs as a side benefit.
Ethical doctors have always worried about the cost of tests and treatments. This topic is nothing new. An example in cardiology would be stress testing. There are three kinds ranging in price from a few hundred to a few thousand dollars. It is unconscionable for cardiologists to only do expensive nuclear tests when simpler kinds using ECG or ultrasound monitoring can be just as good in selected cases.
In the case of pharmaceuticals, many physicians worry about the cost of medications and try to order cheaper generics whenever possible, but the underlying principle is not to worry about cost when spending money on a test or treatment if economizing might cause harm to the patient. The axiom in medicine of always placing the patient’s best interest first has been in place for centuries.
Unfortunately, there are some physicians (and other kinds of healthcare providers) who place profit above professionalism, and that is why I think that including cost into the design of practice guidelines is a worthwhile advance.