Value Judgments

Hopkins Medicine Magazine
Spring/Summer 2017

Three Johns Hopkins experts square off on the ethics of teaching- and promoting - high-value care.

Over the last few years, Johns Hopkins clinicians and researchers have taken the lead nationally to promote high-value care—a movement to improve quality and safety by reducing unnecessary practice while simultaneously reducing costs. 

In March, Johns Hopkins was one of eight institutions recognized by the Leapfrog Group for its “tireless journey of improvement, with one project after another leading [Hopkins] to even greater achievements in quality and efficiency.” And this October, a team of faculty from more than 80 academic medical centers, led by radiologist Pamela Johnson, will host a national high-value health care conference.

It’s against this backdrop that Johns Hopkins medical ethicist Matthew DeCamp and colleague Kevin Riggs have issued a cautionary salvo. In a Viewpoint they wrote for JAMA last December, the ethicists warned that when it comes to medical education, teaching that overemphasizes cost savings could potentially conflict with trainees’ commitment to patient welfare. “If primacy of patient welfare is to truly remain fundamental to the profession,” they wrote, “instilling commitment to this principle should be the most critical ethical value instilled in cultivating professional identity.”

For a candid and wide-ranging discussion about the mission of high-value care and the challenges involved in teaching its tenets to today’s doctors-in-training, we brought together DeCamp, an assistant professor in internal medicine who is affiliated with the Berman Institute of Bioethics; Johnson, vice chair of education for radiology; and Roy Ziegelstein, vice dean for education in the school of medicine.

Smith: Dr. DeCamp, in your JAMA piece, you urge some caution about how high-value care should be integrated into medical education. Among your concerns is that an overemphasis on cost savings too early in a young doctor’s training could lead to bedside decision-making that would not necessarily be in the patient’s best interest.

DeCamp: The reason we use the word “caution” in our paper is the idea that in some circumstances, high value is easy, ethically—because there is health care that’s wasteful. It’s unnecessarily duplicative. It’s ordering a new X-ray on a patient because you think your machine’s better than the X-ray machine that was used just the day before. And those sorts of high-value care decisions to not order such a test—that’s easy.

When you start to move into more complicated value judgments about costs and benefits to patients and to society, that’s where I think it gets a little ethically messy. And that warrants a bit of caution in how we approach teaching the “what” and the “how” of high-value care.

Smith: Could you provide an example of how something that is taught about high-value care to somebody in medical school might play out at the bedside?

DeCamp: One of the concepts we try to emphasize is the notion of unintended consequences of teaching. So as a hypothetical example, you could imagine teaching something like cost effectiveness analysis, where medical students or trainees learn that such-and-such intervention costs $50,000 per life year saved.

And they perhaps erroneously interpret that statement about the cost effectiveness of an intervention at the policy or coverage level to mean that they should restrict or not use that intervention at the bedside.

Now, I’m not saying that necessarily happens, or when that happens, or why. But it’s why we use the word “caution” in teaching high-value care. We need to be aware of the possibility for such unintended consequences - and perhaps even look for them at the same time we’re teaching high-value care.

Smith: Dr. Johnson, as a leader in implementing high-value care at Johns Hopkins and nationwide, how do you weigh in?

Johnson: There’s a very big picture here. We’ve had this model for years in which patient care is not always controlled by doctors. Insurance companies regulate what patients can and can’t do, what they can and can’t get reimbursed for. And that is incredibly dangerous.

We’ve seen instances where patients with cancer can’t get a necessary CT scan because the insurance company won’t pay for it. That’s not high-value practice - that’s cost savings practice, and that’s not what we’re trying to accomplish.

I got involved in high-value care because I think it’s important that the people who define high value are the providers on the ground taking care of the patients. So, taking into consideration that patient care quality and safety are our primary objectives, we will only advocate for practice changes that improve or maintain quality and safety. 

Unnecessary practice carries unnecessary risks. For example, when you subject a patient to a CT scan that’s not necessary, you also subject the patient to radiation exposure, IV contrast administration and a good chance of identifying some other abnormality that you didn’t suspect—which then requires more testing, potentially a biopsy just to prove it’s benign. And you end up going down this path of putting a patient at greater risk for purposes that are not even related to their medical conditions.

Smith: Since 2012, the American Board of Internal Medicine Foundation has led the “Choosing Wisely” initiative, which has enlisted physicians from more than 70 specialties to identify tests or procedures commonly used in their field whose necessity should be questioned or discussed. Are physicians in the field acting on this new information?

Johnson: We have many clinical practice guidelines out there that tell us how to practice good medicine, but people just don’t follow them reliably. 

Why? The hurdles are very multifactorial: fear of litigation, fear of missing a diagnosis, fear of undertreating. And these are the hurdles that we have to overcome by proving that high-value practice can maintain quality and safety. And that’s where our work is.

I absolutely do agree with Matt that safety and quality are the most important issues here. From our perspective, from the provider perspective, it’s about doing what’s best for the patient.

Ziegelstein: I don’t think anyone thinks that we should be focusing on cost and cost alone. We should be focusing on cost reduction and improvement in patient quality and outcomes. So I think we are all in agreement.

What I would say though is that [Matt’s] cautionary note should not be the six-inch headline: It should be the subtext. The six-inch headline is: We’ve got to change the way that we’re taking care of patients and the way that we’re training young people to take care of patients.

In some respects, medical training in this country takes place in a House-like environment.

Smith: The TV show House?

Ziegelstein: Yes. Basically, we often reward young physicians for treating patients like House treats his patients, thinking of every possibility no matter how remote and recommending every test known to man, often with questionable logic. That may work on TV because it produces high drama, however, that is not how we should be teaching young people to practice medicine.

I don’t know of any other trade where the people in training are not taught how much things cost. If you take a medical student or resident or, the truth is, many practicing doctors, and you say to them, How much does a CT scan of the brain cost? they may not even come close.

Here’s an example of what I’m talking about: My own mother is in a nursing home and takes potassium supplements, in pill form, without any difficulty. But over the December holidays a covering doctor decided that instead of having to swallow a pill, she would do better with potassium powder, which comes in a packet. After all, she’s in her 90s: Wouldn’t she be able to swallow the potassium salt in a powder much better?

The doctor had never met her before. The doctor didn’t watch her take the pill and never asked anyone whether she had difficulty with it. The problem is that the powder costs 10 times more than the pill. So $150 rather than $15. That’s thoughtless medicine without consideration of cost.

Smith: So how do we effectively introduce high-value care into the medical school curriculum?

Johnson: We have some innovative ways. My colleague Amit Pahwa created these online modules where medical students take care of a patient, and after taking care of the patient, they order the necessary imaging tests and lab tests. These go into a shopping cart online - like the Amazon.com shopping cart - which shows them the cost. This is just so they get some knowledge of what things cost. I think that’s a great way to teach them; it’s something they can relate to.

Smith: I’ve talked with longtime doctors who say they never talked about costs in medical school because there was this intent to focus only on the patient’s best interest - without potential conflicts. As we move further along with high-value care, do you think there is a danger of patient backlash? Might patients begin to worry that they are being evaluated in purely economic terms?

DeCamp: I would say that if the ethics of high-value care aren’t taken into consideration at the same time as high-value care rolls out, there could be backlash. It could backfire. One way to prevent backlash, ethically, is to ensure that patients are engaged as stakeholders in the design and implementation of high-value care from the start.

And that has been a criticism that’s been levied against Choosing Wisely because Choosing Wisely was largely driven by specialty medical societies. They came out with very reasonable recommendations that were then disseminated to patients through Consumer Reports. From an ethics standpoint, those guidelines might be more justifiable if patients had been involved right from the start, with regard to decisions about value.

Although it’s simple to say benefits over costs; determining what goes into that equation can involve complex ethics and value judgments.

Smith: Could you give us an example?

DeCamp: The example that would resonate with a lot of clinicians is imaging and low back pain. An individual comes in, he has back pain that doesn’t meet any of the red flag criteria for when you would need to order an X-ray or an MRI. But the patient feels that an imaging test would relieve his anxiety about the pain. Does that relief of anxiety count? I think clinicians probably struggle with that and maybe sometimes they order it and sometimes they don’t. And maybe on balance, the recommendation not to proceed with testing still lowers overall costs. But I think that’s the example of a struggle. What goes into the value equation?

Johnson: I would actually have to counter your argument and say that even if the patient is going to be anxious about not having an MRI when it’s not indicated, the right decision is not to do it - even if they suffer a slight amount of anxiety. Because when they get the MRI exam and it shows a renal “something” that then requires a CT scan with contrast and radiation, and then potentially a biopsy of something that might be benign…the patient’s anxiety is going to go up through the roof and the cost is just going to become insurmountable for them. You’re going to go from a $1,500 to $2,000 MRI scan that’s not indicated to a $1,000 CT that’s not indicated to a biopsy - and the time that they have to take off to go get these procedures done as well as the associated risks.

And then there’s the risk of misinterpreting the scan. A new paper just came out in The Spine Journal, where researchers sent a patient with low back pain to 10 different radiology practices for an MRI of the lumbar spine. In many cases, the radiologists overcalled critical findings. The wrong interpretation can result in unnecessary surgery.

So maybe the patient is anxious about not knowing whether or not he or she has a real back problem. But we as doctors know that they have a 99.9 percent chance of not having that problem, and what we need to do is get better at relieving their anxiety and not doing the exam.

Smith: So it sounds like you agree that patient anxiety does play a part in the value equation …What’s the message for patients?

Johnson: There was another great paper in the Journal of the American Board of Family Medicineshowing that we can develop methods of relieving patient anxiety. For example, if you tell the patient: Let’s just do watchful waiting. Why don’t you come back in a week or two and we’ll revisit whether you need this test. This approach was shown to reduce the use of low-value tests.

There is so much work that needs to be done on so many different levels in terms of how we engage patients in this.

I would say, though, that we are the experts, we are the physicians. We have got to be very careful about letting patients be the determiners of whether or not they should have something that’s not indicated.

DeCamp: At the same time, didn’t the Institute of Medicine [Now the National Academy of Medicine, providing advice to the nation on health and health care] say that patients should be at the center of clinical practice guideline development? If that’s true for practice guidelines, shouldn’t it be true for defining value in high-value care? 

Ziegelstein: Remember that it’s not just the trainees and practicing physicians who are divorced from the price of imaging tests, laboratory tests, etc. It’s also the patients. That is until they get the bill, and until insurance declines to pay. Because they’re divorced from the cost at the time of consumption, so to speak, they may not be able to be “educated consumers,” as they might be if they had to go into the store to buy a suit or a sweater.

Now, I recognize that health care is not like buying clothing, however, I agree with Matt that patients need to be brought into the picture, front and center.

Doctors have to get to know their patients better rather than immediately turning to tests. Because it might turn out that just talking to the patient and a careful physical examination may make some tests and procedures unnecessary.

As a doctor, I need to make sure what I’m offering each patient is what he or she actually needs.

Smith: How difficult is it to get practicing physicians, who are used to ordering different tests themselves and they’ve always had good outcomes, to change their mindset?

DeCamp: We know from some evidence on the uptake of Choosing Wisely that it actually has been really hard for physicians to change their practice. Even some of the easy ones—like [not ordering] imaging in nonspecific low back pain without red flags—it’s only 50 percent compliance.

Johnson: Right. Consider the case of transfusions. We were taught to give two units of blood. Anytime the hemoglobin dropped, give two units of blood. And then evidence showed that that wasn’t so good, and the initial attempts to change practice were met with incredible resistance from doctors who’ve been practicing for decades: No, we always give two units of blood, or something bad is going to happen to the patient.

We need to educate providers about the safety outcomes, and reassure them that we are not going to compromise care. And understanding the risks—that every time you give a unit of blood, there’s a whole list of potential complications. So you have to be sure that everything you do that carries a risk is strongly indicated and very much in the patient’s best interest.

Ziegelstein: There is some evidence that students and residents who are trained in areas that practice more high-value care tend to be more likely to choose that high-value care option when they are in practice. What we teach actually matters, which is good news to educators.

Johnson: I got an email today from somebody who trained with us, and they were out at some hospital somewhere. Basically, they said, Okay I am not in an academic center, but please can I join your [high-value care] alliance? We have to reach out beyond our academic centers and get out into the smaller hospitals and help.

Ziegelstein: I think there are three things that need to happen for high-value care to be the norm in clinical practice. First, we have to begin to incentivize and reward high-value care and provide penalties for care that is unnecessary and that doesn’t follow the guidelines of our own specialty organizations.

Second, we need to reinforce the message that practicing low-value care often takes more of a doctor’s time, at least in the long run. Say you order an unnecessary X-ray for low back pain and it shows an incidental finding in the kidney. Now the doctor has to schedule more tests and schedule another visit with the patient about whether this should be watched or whether it’s no problem or whether it needs some other follow-up—and all that takes precious time, which is a commodity for physicians. If you ask doctors in practice, what is their chief complaint, it is: I don’t have enough time. So we need to emphasize that adhering to high-value care actually can save time.

Third, we have to educate the public. Matt is talking about bringing the patient, the public, front and center. I totally agree with that. I think the public, as consumers, as customers, can actually drive the practice patterns of physicians. Patients should demand that their doctor get to know them as a person and thinks carefully about them rather than jumping to tests that may not be necessary. The focus shouldn’t be on cost, but on doing what is right for each patient.

DeCamp: I think we probably all share the hope that the concepts about high-value care that medical students are learning now do get continued and have to be continued as they go through residency and fellowship training and beyond.

Without that sort of continuous reinforcement of the concepts, some of these patterns or the knowledge, the attitudes and the skills may be lost.

But high-value care needs to be tailored to the trainee’s stage as they form their professional identities committed primarily to individual patient welfare. The original subtitle for our paper was, “Walk Before You Run.” The concept is that you introduced the basic parts of high-value care first in med school—say, talking to patients about costs. And then as a resident, you start to teach more complicated issues—say, helping patients decide between treatment options that differ in value. And then you leave more complex decisions integrating benefits and costs into value to more experienced physicians.

It needs to be continuous. It can’t end at medical school or graduation.