Navigating Ethical Tensions in High-Value Care Education

Enthusiasm for high-value care (HVC) is building throughout health care, including in the education of medical students, residents, and fellows.¹ Until recently, medical education has not equipped future physicians with the tools required to practice HVC, or even consider the cost of care they deliver. Quite the opposite: academia often instilled excess over restraint, celebrating trainees who generated (and tested for) the broadest differential diagnosis. Physicians who train in high-spending regions subsequently provide more costly care than those who train in low-spending ones,² making medical school and residency critical times to teach HVC.

Despite the enthusiasm, inherent to the concept of value are potential ethical tensions between patient and societal interests, and different approaches to increasing value may be controversial. In this Viewpoint, we describe this tension in the context of HVC education. We suggest that physicians’ primary commitment to patient well-being—and the process of professional identify formation that cultivates this commitment—may require certain limits to HVC education. Fortunately this can be done without sacrificing the benefits of equipping future physicians to practice HVC.

Value Tradeoffs in HVC

In health care, value is usually thought of as the ratio of health benefits achieved per unit of cost. There are different ways to increase value. One is to achieve better outcomes with less-than-commensurate increases in costs. Another is to achieve the same outcome while reducing costs, such as by eliminating non-beneficial or harmful care (e.g., unnecessary or duplicative tests).

In conceptually distinct fashion, value can also be increased by decreasing costs with a less-than-commensurate decrease in benefit. In some cases, forgone benefits may be trivial (such as imaging in patients with new onset back pain but no other signs or symptoms of serious disease) or outweighed by the benefits of less burdensome health care³ (such as the small increase in cancer risk from performing Pap smears every 3 years instead of annually). In other cases, value can be increased by forgoing expensive interventions that may confer meaningful benefits (such as costly chemotherapy that adds months of life). Common among these conceptually distinct ways of increasing value is permitting a reduction in health benefit for the sake of cost savings, one example of the quality-cost tradeoffs that are common in medicine.⁴

At present, HVC appears to encompass all of these ways of increasing value. Yet physicians and patients may perceive differences among them, particularly regarding whether value is always in an individual’s best interest or in determining what counts as “value” in the first place.⁵

Patient Welfare and Professional Identity

Practicing HVC requires navigating the more general ethical tension between physicians’ commitment to providing cost-effective care while maintaining the primacy of patient welfare without compromise—a tension codified in the Physician Charter on Professionalism and the AMA Code of Medical Ethics. How best to reconcile physicians’ obligations to individual patients and societal resources remains unsettled among ethicists⁶ and practicing physicians alike.⁷

This tension—and the lack of consensus on resolving it—intersects medical education, where professional identity formation (like HVC) is receiving increasing attention.⁷ Professional identify formation is the process by which medical trainees incorporate their own internal beliefs with various external influences to develop a professional identity, i.e., to become a medical professional. The process is developmental, meaning it changes temporally as individuals progress from medical school through residency training and beyond, becoming relatively fixed as practicing physicians.

Although professional identity formation is a complex, multidimensional construct, if primacy of patient welfare is to truly remain fundamental to the profession, instilling commitment to this principle should be the most critical ethical value instilled in cultivating professional identity. Therefore, HVC education for trainees should initially focus on circumstances in which the primacy of patient welfare is clearly fulfilled (i.e., not in jeopardy of compromise), rather than circumstances in which there is ongoing controversy within the profession and society regarding cost-quality tradeoffs and defining value. In these circumstances tension will be less and consensus will be greater.

Implications for HVC Education

Ensuring the profession instills a primary commitment to patient welfare in cultivating professional identity has implications for what and how HVC is taught. Some curricular elements could be viewed as less consistent with this primary commitment to the individual patient. For example, cost-effectiveness analysis could be taught as part of HVC curricula, but without careful attention, this could unintentionally appear to condone unilaterally withholding beneficial treatments for cost reasons, whether the benefits for individual patients are clear (e.g., new hepatitis C treatments) or contested (e.g., life prolonging chemotherapy). These areas of ongoing disagreement are better discussed in the context of societal resource allocation decisions.

How HVC is taught also matters. Competitions during resident morning report to generate the least expensive diagnostic evaluation, asking medical students to allocate a fixed budget among several hospitalized patients, or using dashboards that track and display patient costs for each resident in real-time, could be attractive educational exercises. However, these exercises may obscure differences in the various ways of increasing value, and could risk causing trainees to lose sight of individual patient well-being or create unintended consequences for subsequent bedside decision-making. The least expensive diagnostic evaluation may not be the most technically sound; in some clinical circumstances, even low-yield diagnostics may be appropriate. Although improving general cost-awareness is important, inadvertently influencing real-time medical decision-making for individual patients because of competition or dollars already spent usually is not appropriate.

Medical education can impart the benefits of HVC education without compromising the primacy of patient welfare. Teaching medical trainees to discuss out-of-pocket costs with patients; to avoid wasteful, duplicative, or unnecessary care; and to communicate the rationale for why sometimes “less is more” with patients are all consistent with this. So is increasing cost awareness generally, including the different methods and perspectives–patient, organizational, or societal–from which costs can be calculated. For instance, carefully designed point-of-care price displays could be one means of improving cost awareness.⁹

HVC education should therefore focus on these patient-centered efforts and expand them. Were medical education to succeed in imparting the basic tools trainees need to consider financial implications of clinical decisions and to respectfully communicate about costs with patients, significant progress could be made in promoting HVC without attendant risks to professional identity. On the other hand, ambiguity regarding the primacy of patient welfare in HVC education risks patient distrust and societal backlash against what might be perceived as training future physicians to control costs at the expense of patient well-being.

These recommendations are parallel to medical education in clinical sciences. In content terms, trainees are taught basic disease concepts first (e.g., heart failure management), and advanced management and ongoing controversies in the medical evidence are taught later. Methodologically, trainees are not expected to perform venipuncture or cardiac catheterization as fast as possible; students are taught efficiency later, after basic proficiency is mastered, to avoid ingraining bad habits.

By analogy trainees should first understand the basics of HVC in patient-centered ways. Although trainees should be aware of the ethical tensions present in different conceptions of value, they should not be expected to adjudicate these at the bedside. During the crucial developmental windows of medical school and residency, the principal concern should be cultivating their professional commitments as patient advocates. As trainees advance developmentally, more sophisticated HVC concepts and methods can be taught, just as cardiology fellows eventually learn the intricacies of heart failure management and procedural efficiency.

Conclusion

Amid tension and lack of consensus regarding value, medicine should tread lightly in teaching cost-quality tradeoffs to trainees. HVC education should be tailored to medical trainees’ developmental stage with unwavering focus on the primacy of patient welfare. Ongoing efforts within HVC should monitor not only for the outcomes of their curricula on costs, but also for their effects on professional identify.