There is a national consensus among policy makers and educators that residents should factor the cost of care into decision making - but doctors and those who teach them are not buying in.

In a culture of defensive medicine and unlimited malpractice lawsuits, over-testing is common. And there have been decades of stories and television programs stating that doctors should decide how to treat patients, not insurance companies or hospital management.  Of the
nearly $3 trillion a year spent on health care costs,  30 percent - over $750 billion annually - is considered wasted care that could be avoided without affecting quality, reports the Institutes of Medicine. 

With such runaway costs, the thinking has turned; expenses do matter in a government health care future. Yet less than 15 percent of internal medicine residency programs have a formal curriculum addressing the cost of care. The authors evaluated survey responses from nearly 300 residency programs in the US in 2012. 

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To help address such staggering statistics, in 2010 the Medicare Payment and Advisory Committee recommended that nearly $3.5 billion in funding for graduate medical education be reallocated to as performance-based payments. A year later, the American College of Physicians (ACP) called for high-value, cost-conscious care to become a critical competency for physicians. Dr. Patel was one of the physicians to serve on the ACP's curriculum development committee, which produced the High-Value Care Curriculum in an effort to help residents practice habits of care that reduce unnecessary costs to the health care system.

"Teaching new physicians to practice high-value, cost-conscious care has been recognized as a national priority," said first author Mitesh S. Patel, MD, MBA, a physician at the Philadelphia VA Medical Center and the University of Pennsylvania, one of the physicians to serve on the  he American College of Physicians (ACP) High-Value Care Curriculum
development committee. "In this study, we evaluated whether formal curricula were in fact being adopted by internal medicine residency programs. While we found that this was not the case in the overwhelming majority of internal medicine residency programs, there is hope in that about 50 percent of programs stated they were working on it."

In August 2012, the Association of Program Directors in Internal Medicine (APDIM) survey committee, led by study co-authors Vineet M. Arora, MD, MAPP, of the University of Chicago, and Darcy A. Reed, MD, MPH and Furman S. McDonald, MD, MPH, of the Mayo Clinic, conducted the survey on the state of the cost-conscious care curricula. They evaluated presence of formal curricula, teaching and assessment methods, and perceptions of medical education's role in teaching cost-conscious care. 

85 percent of the programs surveyed agreed that graduate medical education has a responsibility to curtail the rising costs of health care. However, only 47.5 percent agreed that the majority of their faculty consistently role modeled cost-conscious care, and only 33.2 percent agreed that residents had access to information on costs of tests and procedures they order.

Programs in the western United States, those that were university-based and had more residency positions were more likely to have adopted a cost-conscious care curriculum.

"If graduate medical education is going to play a significant role in curtailing the rising cost of health care, it must leverage such models to develop more robust teaching and assessment methods and provide faculty development," the authors write.

The internal medicine residency program at the University of Pennsylvania Health System (UPHS) is among the first programs in the country to adopt a formal training based on the ACP's High-Value Care Curriculum.

During its first year, Dr. Patel taught several of the sessions at UPHS and furthered research on the topic by working with colleagues to develop the VALUE Framework for teaching-hospitals, academic medical centers, and residency programs. It can be used by physician trainees to assess whether a medical intervention will provide value for patients while reducing unnecessary spending. It includes deciding the most appropriate medical tests to order, selecting the most cost-effective medications to prescribe, and discussing with patients whether or not to have surgery.

"There's a lot of work ahead as we look for ways not only to expand adoption of these curricula, but also to find ways to better standardize teaching and assessments methods that can be better implemented during residency training," said Patel. "Early adopters of cost-conscious care curricula should look for ways to further its efforts by studying its impact on physician training and patient care."

 Published in JAMA Internal Medicine.