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COMMENTARY

Medical Education Contributes to Culture of Overuse

In a commentary, NC Health News contributor Nancy Wang, who has completed three years of medical school at UNC-Chapel Hill writes that medical training contributes to overuse of expensive testing, training doctors to function in a way that continuously increases cost.

By Nancy Wang

Even after completing three years of medical school at the University of North Carolina, I still have trouble identifying abnormal heart sounds. But if I’m given the lab results to the most simple and routinely ordered blood test, I can immediately tell if the patient has an infection, has signs of leukemia, is low on certain vitamins and minerals, needs a blood transfusion or is having problems forming clots and may be at risk for severe bleeding.

Unfortunately, I’m not alone in my reliance on medical technology.

Earlier this year, the Institute of Medicine (IOM) released a report stating that of the $2.5 trillion spent on health care in the U.S. in 2009, approximately $750 billion was wasted on unnecessary treatments, ineffective services or missed opportunities for preventive care.

“This isn’t new,” said Sue Tolleson-Rinehart, an adjunct assistant professor of political science at the University of North Carolina at Chapel Hill. “The opportunity to overuse and misuse technology in health care began when the technology itself began in the ‘70s.”

According to the IOM report, the largest category of waste was an estimated $210 billion that was spent on tests, medications and services that were not needed or supported by current medical evidence. This problem is referred to as overuse or overtreatment in the medical field.

Graphic comparing overuse of testing in medicine to unnecessary technology in factories

Infographic courtesy US Institute of Medicine.

“We’re human beings. If you put a tool in our hands, we’re going to use it, and we don’t necessarily use it so well,” said Tolleson-Rinehart who is also the assistant chair for faculty development at the UNC School of Medicine.

Hospitals, insurance companies and even tech industries are all trying to find ways to get doctors to use the tools we have effectively and efficiently. Many hospitals are offering doctors financial incentives to cut back on tests, whereas insurance companies are threatening to reduce reimbursements to physicians who use unnecessary services. Medical tech industries, on the other hand, are creating electronic medical record systems that help track, identify and reduce overuse.

All of these approaches, however, overlook the root of where this habit of overuse starts: medical school.

Part of the problem stems from the structure of the U.S. medical education system. Currently, the majority of U.S. medical students spend the first two years studying basic sciences and learning how to perform a physical exam. Then, during their third and fourth years, they enter the clinical setting and actually take part in the care of patients.

This division can lead to a disconnection between physical exam skills and actual diagnostic skills.

“In the first two years we were taught physical exam skills in small groups and lectures, but the emphasis was dropped during the third year,” said Elena Adamo, a fourth year medical student at UNC. “Instead, we spent more time learning about tests, labs and drugs than we did about how to diagnose patients from examining them.”

Many medical professors agree.

“I do feel like we’ve lost the physical exam in the last 30 years because we’ve focused more on basic sciences,” said Dr. Kurt Gilliland, assistant professor of anatomy and neurobiology at UNC School of Medicine. “Assessments also drive instruction, and in the basic sciences we want to test objective things such as lab values and x-rays, so that is what we end up teaching.”

gloved hands labeling blood tests

Image courtesy Neeta Lind, Flickr Creative Commons

Given such training, it’s no surprise that the current health care system places a similar emphasis on labs and test results.

According to estimates provided by Judy Melton, who works in revenue management at UNC Hospitals, one of the most routine blood tests ordered by physicians, a complete blood count with differential, costs approximately $91 for the test and $31 for the physician to read it. Other less routine but still common tests such as a CT scan of the head, which is basically a 3-dimensional X-ray of the head, can cost up to $1,538 with an addition $724 for the doctor to read the scan.

Even for patients with insurance coverage, the costs of these tests can add up quickly. And for the country’s overall health care bill, excessive use of these tests easily contribute to the wasteful spending reported by the Institute of Medicine.

A physical exam, on the other hand, doesn’t cost patients anything extra. Indeed, it is the essence of what patients are paying for when they go to see their doctor, whether they get it or not.

So in the midst of the current political spotlight on how the Affordable Care Act and other policies will affect U.S. health care expenditure, more focus needs to be placed further upstream to where it all starts.

“We need to change medical education back to a more patient-centered orientation where we use diagnostic tests and imaging to enhance doctors’ understanding of their patients and not to replace their knowledge of their  patients,” Tolleson-Rinehart said.

Instead of just spending billions regulating, punishing and coercing physicians and other health care providers to be more efficient, it may be necessary to re-evaluate our current medical education system and figure out how to train more efficient doctors to begin with.

Nancy Wang completed her third year of medical school and is completing a masters in public health this year at UNC-Chapel Hill.

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