THE rising cost of health care and tight economic times have prompted discussion about cost-effectiveness in health and the need for more fiscally minded or “restrained” health professionals.
An article recently published in JAMA called into question the fundamental way in which we learn medicine — the apprenticeship model, predominantly in resource-rich tertiary hospitals. The authors held that the current model rewards thoroughness and discourages restraint.
They called for improved teaching and discussion about cost-effectiveness, efficiency and priority-setting as part of medical education.
However, my experience as a medical student suggests that perhaps the problem lies elsewhere and is one that is more difficult to address.
Throughout my clinical training, there has been formal teaching in health economics and many casual discussions with more senior clinicians about the costs, risks and benefits of various tests.
We are encouraged to be thorough in our thinking, but that this does not necessarily mean ordering superfluous tests, or starting or continuing futile treatment. I have been reminded regularly to consider the cost and necessity of specific tests and treatments before ordering anything.
We have had ethical discussions about priority-setting and the cost of end-of-life care and intensive care units when compared with primary care and health promotion. The education and dialogue around health economics, cost-minimisation, cost-effectiveness and restraint could not have been much more thorough.
So, where does the problem lie? And why is the medical community continuing to overprescribe and overinvestigate? I believe the major contributing factor is the environment in which we work.
As Professor Michael Jelinek asserts, our fear of litigation undoubtedly plays a role.
Doctors, particularly at a junior level, work in an environment in which they are simply too scared to miss a diagnosis — scared of both litigation and their superiors. At a junior level, lack of experience and clinical acumen means we often require more information than senior colleagues to reach the same conclusions. We want to be seen as competent by our superiors, so we order more tests and get more information to work with.
Poor information-sharing systems also contribute. All too often we find tests have been repeated unnecessarily because two different teams are involved in a patient’s care, or because the hospital medical team has not contacted the patient’s GP, who already ordered all the tests needed. Sometimes these can be simple blood tests, but I’ve also seen lumbar punctures, CT scans, MRIs, and even colonoscopies unnecessarily repeated as a result of poor communication.
Clearly, health economics and cost-effectiveness must remain critical components of medical education and training. While my experience has been positive, the experience of others is different, and many clinicians want further training about cost-effectiveness.
To truly effect cost-effective change in the medical profession, we need to take a comprehensive approach to change the environment in which we practice rather than simply focusing on medical school curriculum.
Ms Zoe Stewart is a final year medical student at Monash University, a Master of Public Health student at the University of Sydney, and public relations officer for the Australian Medical Students’ Association.
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