The Right Choice?

Surgeons and the Ethical Imperative of Efficiency


In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

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