Cost Consciousness in Medical Education

 Teaching cost-consciousness to the medical student has often been framed as a paradox. How can we teach the student to always think in the best interest of the patient while at the same time asking him or her to consider the cost to the medical system? I would argue that teaching medical students to become aware of costs will not necessarily drive them to choose less effective investigations or interventions, but rather to be able to identify the more cost-conscious of two equally appropriate options. This discussion, then, focuses not on ethical dilemmas but rather on informed decision-making.

Central to the issue is a consideration of barriers that may prevent an individual from making cost-conscious healthcare decisions. Perhaps the most obvious element of informed decision making is lack of knowledge of all available options. This is very relevant for the medical student who is only becoming acquainted with management and who, for lack of exposure, may be familiar only with the most common course of action at a given institution. Beyond knowledge of available options, many physicians lack knowledge regarding costs of those options. After all, never on ordering or an intervention or on its completion do we see the bill. Some have argued that, for example, labelling antibiotics with their cost in the ordering system may drive physicians to make more fastidious choices (sorry for the pun).

But let’s take the discussion one step further. Even if we did ask medical students to familiarize themselves with the cost of every available intervention, it would remain extremely difficult to comprehend the effect of any given choice on the medical system. After all, the effect is a summation of many separate decisions made by different individuals, which can lead the individual to think, well, ‘what’s the big deal’. Especially when there is a sick patient sitting in front of you, and the bigger, more expensive, ‘shotgun approach’ is often the most comforting to both patient and provider. The implication here is that cost-consciousness in practice will require not only information about costs but also a culture change in that we should feel responsible to consider costs in our decision-making. Our focus in medical education, then, should not necessarily be to teach students all the available interventions and their cost (which will change over time anyway), but to highlight situations in which a cost-conscious decision is being made so that this becomes a central element of the decision-making process.

-Sarah