Traditionally, medical students haven't been taught how to talk with their patients about the costs of treatments and medications. The thinking was that doctors should offer their best advice to all patients, regardless of their insurance or ability to pay.
But in a huge departure from the past, the vast majority of the country's medical schools now integrate discussions of cost, value and effectiveness into their curricula.
It's "a dramatic change," says Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, which helps medical schools develop curricula.
A recent Association survey finds that 129 of 140 responding medical schools said they offered a required course on the cost of health care during the 2013-2014 school year. Nearly 40 percent of the schools said they also present the issue in elective courses.
Among the reasons for this change: The Affordable Care Act, which rewards doctors for providing high-value care, not for how many tests they order or surgeries they perform.
Another reason is that more people now have high-deductible health plans. More patients now have to pay a lot for their care before insurance picks up the tab, and that's spurring some to become cost-conscious consumers.
As a result, Orlowski says doctors now have a responsibility to consider the costs that patients might face.
"We are recommending that in relative terms, that physicians understand cost, and they take that into consideration when making their best recommendations," she says.
Adding value to 'every discussion'
In Southern California, medical schools and residency programs are developing their own ways to insert cost and value into their curricula.
Since 2012, the Keck School of Medicine of USC has offered a Business of Medicine course that discusses the cost of care. UCLA's David Geffen School of Medicine started weaving these themes into daily lessons last year, and will be doing so on a much larger scale this school year, says Dr. Reshma Gupta, who is leading the effort at UCLA.
"In the everyday teaching they get about clinical medicine, what medications to prescribe, what's the name of this diagnosis, we're going to add a layer to every discussion about the value part of that as well," Gupta says.
About a dozen first-year residents at UCLA recently got an introduction to this discussion. Sitting around a table in white lab coats, they learned definitions for three health care terms – cost, charge and payment – through a car metaphor.
"Producing the car might be $10,000, but the price on the window might be $20,000, and then you might end up giving them $18,000, so that's cost versus charge versus payment,” explained Sara-Megumi Naylor, a UCLA chief resident.
Some students have pushed back against these types of lessons.
"They're so busy trying to master the basics of medicine, the science and the interpersonal skills, that I think it feels sometimes like this is one more issue they're being asked to master, when they have so much on their plate already," says Dr. Paul Lyons, senior associate dean of education at the UC Riverside School of Medicine.
This information often resonates more deeply once students and residents see its direct impact on patients, Lyons says.
But getting buy-in from students is just one challenge. Another one is getting older doctors to adopt this new approach, which they never learned in medical school. It often falls upon students and residents to spur these conversations in clinics and wards, says UCLA's Gupta.
When trainees suspect there's a more cost-effective alternative, Gupta says she teaches them to say to their superiors: "I value your experience and why you're saying this, but I also read this journal article that tells me that maybe we should be using this antibiotic instead of this one, or doing this test instead of this more expensive test. What are your thoughts on it?"
'Does that actually serve the patient?'
UC Riverside medical student Isaiah Roggow got a dose of all of this while volunteering at the school's free clinic, housed at a church in downtown Riverside.
He recalls one clinic patient with high levels of blood protein. He says much of the time that doesn't mean anything, but a doctor recommended testing for a type of cancer.
It turned out the clinic doesn't offer that test, because of its $400 price tag. Looking back, Roggow says that would be a lot to spend for a test that could prompt more questions but give few answers.
"Most of the time, when it's a positive test, it actually means we just have to do more tests," Roggow explains. "And does that actually serve the patient at all? Now they're just worried because they have this abnormal test that stresses them out, maybe for nothing."
Learning how to balance cost with effectiveness: That's a lesson that more and more medical schools are now trying to teach.