Elisabeth Askin is a third year medical student at Washington University in St Louis and co-author of The Health Care Handbook for medical students.
In 2008, I volunteered at the San Francisco General Hospital Emergency Room, enrolling patients in research studies. One study correlated clinical signs in trauma patients with positive findings on chest x-rays, so that orders could be better informed and more efficient. And efficiency was certainly needed - I was stunned to learn that only 3% of trauma chest x-rays yield positive results. That’s a lot of time, money, and energy for very little useful information.
We may not doubt the judgment of those ER physicians, but we also know that each clinical decision has an effect on the national bottom line. Health care costs in the U.S. have reached 17% of GDP and continue to rise. Everyone agrees that our current situation is unsustainable and that change is necessary.
Cost is not the only way that the individual, daily behavior of providers and patients combine to form a larger picture. Obvious examples include rising antibiotic resistance and defensive medicine. Less obvious examples include off-label prescribing and the obesity epidemic. Whether we recognize it or not, all of our actions are affected by – and in turn affect – larger societal trends.
Thus, the question is: how do we combine doing what is best for each patient with understanding our role in the larger picture?
For one thing, we need to have an idea of what that larger picture is. Medical students not only don’t know about prices – they often aren’t familiar with the most basic aspects of health care delivery, policy, insurance, economics, drugs & devices, or reform. It’s not because of a lack of interest but rather because getting a view of the larger picture isn’t easy.
The news and blogs provide a ton of details without the scaffolding to connect them. Popular books often provide one-sided arguments. And scholarly books mostly offer highly detailed knowledge about solitary aspects of the system – which may obscure the forest in favor of a leaf. Meanwhile, schools usually only expect us to know that Medicare covers the old while Medicaid covers the poor.
Students shouldn’t have to work hard to cobble together an understanding of what an HMO is, how an NP differs from an RN, or what the options are for the uninsured. While trying to learn these things on my own, I found myself wishing for a dummies’ guide or a single reference, but to no avail. So a fellow medical student, Nathan Moore, and I decided to write our own.
The Health Care Handbook: A Clear and Concise Guide to the U.S. Health Care System introduces the key facts and foundations that make the health care system work. The book includes balanced analyses of current challenges and controversies in health care, including medical errors, government regulation, medical malpractice, high drug prices, and much more. And, no surprise to anyone reading this site, we devoted an entire chapter to insurance and economics.
Medical students, residents, and attendings should know how much a chest x-ray in the ER costs, but that’s not all. They should also know how few trauma chest x-rays show any findings, how little care in the ER gets reimbursed, that hospitals are building new cardiology wards to offset those costs, and what kind of testing the new devices in the cardiology wards have to go through.
We need to make sure that our behavior, while always determined by the patient in front of us, rationally and practically acknowledges the system in which we work. Those of us in medical school now know this will play larger role in our careers than it ever has before. It’s time to start asking for more education about it.