In America's Hospitals, Reforming Responsibility and Medical Education

As a current medical school applicant I’ve been repeatedly asked to reflect on personal challenges, moments when I’ve stepped outside my comfort zone, and the role of compassion in the physician-patient relationship. But, not once has an application essay probed my understanding of the health care system or sought my opinion of health reform. Increasingly, I understand this omission not as a mere oversight, but rather as reflective of a systemic neglect in the training and professional development of our health care providers.

In 2010, Americans spent approximately 20 percent of our GDP on health care, a figure projected to rise over the coming decades. Portions of President Obama’s landmark Affordable Care Act seek to reign in these costs by affecting changes in the flow of dollars from patients to insurers to providers. The assumption made by most Americans is that legislators, insurers, and hospitals are to blame for the rise in costs and so are equally responsible for reform.

Unfortunately, few understand the role of physicians in constraining our health care spending. Perhaps more worryingly, little effort is being made to educate future doctors about implications for their practice.

Since the early 1970s, Dr. John Wennberg and his colleagues at the Dartmouth Institute for Health Policy and Clinical Practice have made a name for themselves as a benevolent gadfly in the medical community by publishing groundbreaking research into the variation in the way doctors practice medicine. Many Americans would be shocked to learn that this variation does not stem from differences in illness or their own desire for more medical interventions, but from physicians themselves.

In a body of more than 300 publications, the Dartmouth team has repeatedly demonstrated that just 15 percent of medical spending is directed toward the provision of evidence-based, “effective care,” while a large portion of the remainder is governed by provider preference, termed “preference-sensitive care,” which may not adhere to the care guidelines established for a given condition.

Preference-sensitive care delivery stems from the proclivities of individual doctors, such as the tendency of surgeons in one town to perform more tonsillectomies than those in an adjacent town despite the absence of substantial demographic or health status differences between localities. This type of practice variation is also indicative of a medical system that often neglects the voice of the patient in making decisions about their own health care, and instead relies on physicians’ own opinions and preferences to direct the decision-making process.

The recent health reform legislation takes steps to curb insurer abuses and encourage Americans to take greater responsibility for their heath care; however, with so much of health care spending directed by individual physicians, it is vital that we also remedy the problems associated with unwarranted variation in practice. Reimbursement systems that reward physicians for the quality, not the quantity, of care delivered are an important part of this process. Likewise, macroscale organizational changes to integrate and coordinate health care in the accountable care organization model currently under development hold the promise of reducing cost by streamlining patient services and eliminating duplication and wasteful excess treatment.

Yet, as John Wennberg notes in his recent memoir, Tracking Medicine, this process entails, “transforming a gargantuan industry whose growth has been driven in part by deeply held … beliefs about the nature of health care markets, the scientific underpinnings of medicine, and the power of more care to heal.” The methods and processes of American medical schools have changed little over the last century and resistance to accepting the onus of cost control is a deeply ingrained principle of professional medical societies. Physicians themselves must now match the efforts of Congress and corporate interests to solve our health care crisis. Lasting change in health care will only be possible if our medical schools and accreditation boards develop methods to train new physicians to recognize the unwarranted variation in practice that encourages preference-sensitive care and paternalistic medical decision-making.

At some point in their past, all of today’s physicians penned admissions essays similar to those I am currently drafting. In assessing their personal role in fixing the problems of American health care, these doctors should again reflect on the topics of challenge, comfort zones, and compassion for patients. The costs of resisting change are too great, both in terms of finances and the quality of patient care.

Photo Credit: Vix Walker

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Andrew Wickerham

Andrew Wickerham is a medical student at the Tulane University School of Medicine in New Orleans. He completed his Master of Public Health degree at Dartmouth Medical School and his Bachelor's degree in history at Colgate University. He has worked with the New America Foundation in Washington, DC on issues including shared decision-making in medicine and definitions of value and productivity in health care. His research interests include primary care systems, reimbursement reform, and the interactions between young adults and the health care system.

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