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In a large lecture hall of fellow clinicians-to-be, I was told that my job as a physician is not to be concerned with costs but rather to treat patients. My wrist, moving frantically left to right on my page taking notes, stopped. I looked up and my mind wandered: What an odd message to tell those who will be listening to ill people's symptoms, prescribing medicine, ordering tests, and orchestrating people's care to not worry about costs.

We have set up this dichotomy of treating the patient or being concerned with costs. We have soaked medicine with the belief that cost-conscious care is rationing at the bedside and the public is fed fear messages that clinicians who care about costs are limiting their care. How can we teach future clinicians to be so out-of-touch with one of the greatest concerns that many patients have when seeing a clinician? We know that people forgo medications because of high prices, medical bankruptcy plagues many, and that some cannot seek care due to cost. What other industries allow someone so crucially involved in controlling costs immunity from worrying about them? Does medicine's unique role of saving lives exempt it from keeping an eye on the register? Is good care not cost-conscious care?

Clinicians do not have the luxury to not care about costs.

—adapted from Sarah Jorgenson, Costs of Care, 2013

As Sarah Jorgenson eloquently highlights, teaching medical students how to consider costs while caring for patients is uncommon—in fact, clinicians are often taught to specifically ignore costs. But times are changing, and recently, there have been increasing calls for medical education to train cost-conscious physicians.1 Educating physicians to be “cost aware” is now becoming a critical responsibility of medical schools and residency programs. The Accreditation Council of Graduate Medical Education (ACGME) has included cost awareness and stewardship into its systems-based practice competency; residents are asked “to incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.”2 To raise the visibility of this need, the American College of Physicians (ACP) has proposed that high-value, cost-conscious care be added as a standalone “7th core competency” of residency education.3


Although current efforts to integrate value-based care into medical training may appear new, it may be surprising to learn that such efforts actually date back to as early as 1975! In that year, Harvard Professor of Medicine Dr Howard Hiatt famously encouraged physicians collaborate with other experts and the public to protect the medical commons (see Chapter 5).4 In 1984, UCSF Professor of Medicine Dr Stephen Schroeder and colleagues rigorously evaluated an educational intervention, which included a weekly lecture as well as audit and feedback, designed to reduce lab and radiology use at the University of California at San Francisco (UCSF). Unfortunately, ...

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