I'm on a two week rotation as inpatient attending on the Solid Tumor service at Hopkins through the end of August, and this morning before rounds I gave a short lecture to the medicine housestaff and the oncology fellow on service about the ABIM's Choosing Wisely campaign, specifically ASCO's Top Five list, or "opportunities to improve quality and value in cancer care." This is a little bit of an offbeat topic for our morning lectures, as usually we cover some area of inpatient management of a common oncologic condition like febrile neutropenia or a disease-specific talk. Not too surprisingly when I asked them if any of them had heard of Choosing Wisely no one had. We didn't have much time for discussion, so I wasn't able to spend much time seeing their reactions, but they did seem to be paying attention to me (or they daydream well with their eyes open). Perhaps I made a slight impact, since later in the day, in discussing the management of a specific patient, one of the residents reflected out loud whether we really should be ordering a CT on this patient, since they had just had prior imaging that perhaps was sufficient.
Coincidentally, I read a blog post this morning on the very same topic from Vineet Arora, who is an academic hospitalist and the associate program director for the internal medicine residency at University of Chicago. In Teaching Costs of Care: Opening Pandora’s Box she writes about an interesting pilot video vignette being used at her institution to stimulate residents into thinking about the costs of ordering tests. Some of the discussion she captures, about how residents express concerns about malpractice and how to handle patient demands, is pretty interesting.
So I ended my brief talk this morning by reminding the housestaff that, since everyone agrees that the trajectory of the cost of medical care in the U.S. is unsustainable, it was their generation's responsibility as physicians to help come up with solutions and leadership in this area. God knows when and how our tortured reimbursement system in this country is going to change to reward quality and outcomes and not quantity of services. I just know that by the time I am eligible to dip into the Medicare Trust Fund in another 13 years or so, the new generation of physicians better be the ones who have solved this clinical and regulatory mess, since my generation has been spectacularly unsuccessful at making any headway.