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Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine–American College of Physicians Curriculum

Cynthia D. Smith, MD, on behalf of the Alliance for Academic Internal Medicine–American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee*
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From the American College of Physicians, Philadelphia, Pennsylvania.

Acknowledgment: Special thanks to the AAIM, ACP, and ABIM Foundation for their support and vision and to the following persons for reviewing the curriculum: Patrick C. Alguire, MD, Senior Vice President, American College of Physicians; Steven E. Weinberger, MD, Chief Executive Officer, American College of Physicians; Vineet Arora, MD, MA, Associate Professor of Medicine, Assistant Dean for Scholarship and Discovery, Pritzker School of Medicine and Associate Program Director, Internal Medicine Residency Program, University of Chicago; P. Preston Reynolds, MD, PhD, Professor, General Medicine, Geriatrics and Palliative Care, University of Virginia School of Medicine; and Edward B. Warren, Manager, Education and Career Development, American College of Physicians.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1519.

Requests for Single Reprints: Cynthia D. Smith, MD, Senior Medical Associate, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, dsmith@acponline.org.

Author Contributions: Conception and design: C.D. Smith.

Drafting of the article: C.D. Smith.

Critical revision of the article for important intellectual content: C.D. Smith.

Final approval of the article: C.D. Smith.

Administrative, technical, or logistic support: C.D. Smith.

Ann Intern Med. 2012;157(4):284-286. doi:10.7326/0003-4819-157-4-201208210-00496
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Health care expenditures are projected to reach nearly 20% of the U.S. gross domestic product by 2020. Up to $765 billion of this spending has been identified as potentially avoidable; many of the avoidable costs have been attributed to unnecessary services. Postgraduate trainees have historically received little specific training in the stewardship of health care resources and minimal feedback on resource utilization and its effect on the cost of care. This article describes a new curriculum that was developed collaboratively by the Alliance for Academic Internal Medicine and the American College of Physicians to address this training gap. The curriculum introduces a simple, stepwise framework for delivering high-value care and focuses on teaching trainees to incorporate high-value, cost-conscious care principles into their clinical practice. It consists of ten 1-hour, case-based, interactive sessions designed to be flexibly incorporated into the existing conference structure of a residency training program.





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Validity of Assumptions Questionable
Posted on September 6, 2012
Barry Kisloff, MD, FACP
Conflict of Interest: None Declared

To the editor:

The article by Smith (1) concerning the creation of a curriculum to instruct physicians in the provision of "high-value,cost-conscious care" makes several assumptions which are of dubious validity.There is the unfounded belief that sufficient high quality evidence based pathways (EBP) exist to provide a framework of instruction toward the above noted goal. Most commonly encountered health care issues are engulfed in legitimate controversy (2) (3) (4) and, with ongoing research, an EBP modestly valid today might well have little legitimacy in the near future. Providing even the best supported EBP recommendation must still be tempered by patient preference (5) and the threat of litigation should an enforced best practice-cost conscious pathway yield an undesired result. The article further suggests the communion of medical trainees, medical faculty and hospital administrators in order to establish pathways for cost-conscious care. This seems  a curious troika when one examines the current reimbursement system which provides no incentive for physicians and hospital administrators to seek the most cost efficient pathway (6).

Finally and predicatably, the ACP and AAIM would seek to codify and thus validate a tenuous knowledge base by placing questions on examinations the "correct" answers to which likely rest on a fragile factual underpinning and poorly fit the socio-political climate in which clinicians operate.


(1) Smith CA. Teaching high-value, cost -conscious care to residents: The Alliance for Academic Internal Medicine-American College of Physicicans. Ann Intern Med 2012;157:284-286.

(2) Bayer R, Oppenheimer GM. Routine HIV screeninig-what counts as evidence based policies? NEJM2011;365: 1265-1268.

(3) Sox HC. Quality of life and guidelines for PSA screening. NEJM 2012;367:669-671.

(4) Gotsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet 2000;355:129-134.

(5) Quill TE, Holloway RG. Evidence, preferences, recommendation.Finding the right balance in patient care. NEJM 2012;366:1653-1655.

(6) Rauh SS, Wadsworth EB, Weeks WB, et al. The savings illusion-why qualityimprovement fails to deliver bottom-line results. NEJM2011;365:e48. Barry Kisloff MD, FACP, University of Pittsburgh Medical Center.


Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine-American College of Physicians Curriculum.
Posted on September 10, 2012
Vichai Atichartakarn, MD, FACP
Faculty of Medicine Ramathibodi Hospital, Mahidol University
Conflict of Interest: None Declared
TO THE EDITOR: I mostly agree with the recent article by Smith and colleagues (1). As a faculty member of a university hospital in Bangkok, I am aware that we are facing the same problem of skyrocketing medical care costs, which in my opinion are due mostly to us, the medical care providers. Because my colleagues and I work in a limited resource country, it is even more crucial to us to tackle this problem effectively.There are two parts in medical care cost, diagnostic and therapeutic. I will discuss only the first part because I believe it applies everywhere. To lower costs, I have been recommending that we devise five columns for any test we plan to order. The first column is for the name of the test, the second is for the reason for doing it, the third is for the expected result, the fourth is for the actual result, and the fifth is for the action taken after knowing the result. This tool is very good for achieving clinical precision and accountability. If we implement this, in conjunction with grading the decision, I am confident that the number of tests will decline dramatically. We should institute this tool among both medical students and house staffs. I have observed that many tests can be avoided if one takes a good history, performs a thorough physical examination, and correlates these with bedside monitoring data, if any. This tool encourages critical thinking. While this takes time, it avoids the usual knee-jerk decision. Ordered tests should be guided by clinical impression. However, in the real world, it is not unusual to hear house staff discussing laboratory results which are rather irrelevant to the patient. It is sad to say that we are living in a laboratory-oriented world in which we too often fail to understand fully the bases and limitations of tests. Thus, many tests are ordered that have no impact on treatment decisions, where no account has been made of potential costs and harm to patients. Ordering tests to “cover the bases” has become a wasteful and costly norm. It is time that we rigorously apply techniques that can ensure high-value, cost-conscious care before we all go broke from mounting medical care costs.Vichai Atichartakarn, MD, FACP Emeritus Professor of MedicineFaculty of Medicine Ramathibodi Hospital, Mahidol UniversityBangkok 10400, Thailand. E-mail: vichai.ati@mahidol.ac.thPotential Conflicts of Interest: None disclosed.Reference1. Smith CD. Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine-American College of Physicians Curriculum. Ann Intern Med. 2012;157:284-286.
Author's Response
Posted on October 2, 2012
Cynthia D. Smith, MD
On behalf of the Alliance for Academic Internal Medicine–American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee
Conflict of Interest: None Declared

Dr. Kisloff expresses concern that there is insufficient high quality evidence to provide a framework for instruction in this area and cites controversies about HIV, PSA, and breast cancer screening as examples. The complexity that surrounds many clinical decisions is precisely why this curriculum provides a framework for trainees to approach clinical decisions in an organized, stepwise fashion. It includes customizing the plan to reflect the individual patient’s values and concerns while warning against the practice of “one size fits all” medicine. Clinicians need to make decisions even when the available evidence is insufficient and/or controversial, and the curriculum provides practical tools to help with these decisions. The curriculum also focuses on the unwarranted use of imaging studies and laboratory tests where there is clear guidance from a number of credible sources, such as imaging patients with non-specific low back pain or uncomplicated headache (1, 2).

Another concern voiced was that medical trainees, faculty, and hospital administrators are never incented to seek the most cost-efficient pathways. As the payment structure will be incorporating value-based incentives, there are financial reasons to control costs of unnecessary testing and treatment while improving patient outcomes (3). The concern that the in-training examination sub-score would be based on fragile factual underpinnings is unfounded. This aspect of the evaluation tests the trainee’s understanding of evidence-based recommendations to refrain from ordering unnecessary tests or procedures where the cost and harms clearly outweigh the benefit. These questions have been developed using a rigorous review process similar to that used by the ABIM and USMLE (4). This subscore is only one component of a multimodal evaluation of the curriculum’s effectiveness.

Thanks to Dr. Atichartakarn for his comments about the need to train residents to systematically approach diagnostic test ordering. The five columned chart he describes in his letter may be combined with the approach we recommend in the curriculum from the article, High value testing begins with a few simple questions, to create a useful chart extraction or resident evaluation tool (5).


1. Chou R, Qaseem A, Snow V, et al.; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147:478-91. 5;148:247-8.

2. Jordan JE, Wippold FJ II, Cornelius RS, Amin-Hanjani S, Brunberg JA, Davis PC, De La Paz RL, Dormont D, Germano I, Gray L, Mukherji SJ, Seidenwurm DJ, Sloan MA, Turski PA, Zimmerman RD, Zipfel GJ, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® headache. Reston (VA): American College of Radiology (ACR); 2009. 8.

3. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2011. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system changes and FY2012 rates; hospitals’ FTE resident caps for graduate medical education payment. Final rule. Federal Register 76, no. 160 (August 18): 51476–51846.

4. Babbott SF, Beasley BW, Hinchey KT, et al. The predictive validity of the internal medicine in-training examination. Am J Med. 2007;120:735-740.

5. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

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