Issue 44 / 12 November 2012

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.

Posted 12 November 2012

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3 thoughts on “Zoe Stewart: Doctrine of restraint

  1. University of Tasmania says:

    The medical world needs to be more clear about how it measures illness, prevention and deterioration. Primary Health Care and Health Promotion have to be more expectant of good outcomes, just as the diagnostic madical profession is. Obesity has now surpassed cigarette smoking in its cause of mortality…but everyone knows that.

  2. Rebecca says:

    I still remember as a 1st year intern holding a patient’s blood tests, including full hepatitic screen, a chest xray and an upper abdo ultrasound all organised by the GP who referred the patient to the emergency department. When I didn’t repeat all the same tests, I was told off by my both the medical registrar and my supervisor. I am unsure how repeating the same tests would have given more information.

    Another intern story, the patient who had an outside CT scan which reported ?lumbar discitis. The scan was “lost” between the emergency dept and the ward. The only record was a small note in the ED recorded notes, which had failed to be communicated between doctors, and not re-read until some days later. The patient symptoms were of fever, patient proceeded to have (a second) chest / abdo / pelvis CT amongst other investigations, which showed … lumbar discitis. (Note that the “diagnosis” wasn’t clear to the treating team for several days).

  3. Bruce says:

    Medical education on restraint is adequate. The problem as pointed out is rooted deeply in medicolegal risk.

    I think there should be more emphasis on financial restraint, cost effectiveness and efficiency in patient education.

    Public expectation of the infallibility of doctors is disproportionate to the medical profession’s ability to deliver at an individual level. We accommodate this by spreading the risk.

    The ethical public should skew their view towards justice and away from autonomy. If they knew how much it cost, they would be more cautious with their expectations of a finite resource.

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