Doctors should weigh costs in treatment, ACP says

Physicians should consider data on cost-effectiveness when making treatment recommendations and ought to behave professionally when using social media.

Those are among the recommendations in the sixth edition of the American College of Physicians' ethics manual, updated for the first time since 2005 to include guidance on topics such as genetic testing, catastrophic care and pay-for-performance.

Doctors have a responsibility to deliver "parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient," says the college's policy on cost containment. Whether treating individual patients or serving on panels that write formularies and guidelines, doctors should make decisions based on "the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches," the guidance says.

"Physicians have to start to personally think about how they use resources in the care of individual patients," said Dr. Virginia L. Hood, MPH, the college's president. "In the past, there's been a little feeling that you just do whatever you think is right for the patient and you don't think, for example, about whether you've done the test twice or whether someone else already did it.

"Physicians have always tried to do the right thing for patients, and the prime responsibility is always individual patient care and doing the best for individual patients. But we have to start to look a little more closely at what are some of the best alternatives for care that take into account effectiveness, cost and not doing harm. It's the not-doing-harm that we really want to emphasize. Every time you give a test and do a treatment, there may be potential for harm as well as extra cost."

The college's cost-control advice should not translate into always choosing the cheaper treatment option, said Dr. Hood, professor of medicine in the Dept. of Nephrology at the University of Vermont College of Medicine. Individual patient outcomes vary significantly, despite randomized controlled trials that may show equivalency between two drugs, for example, in the "average" patient.

"Those of us in practice seeing patients every day -- we make these judgments all the time," she said. "That's why we need physicians, not an algorithm, to say, 'This is what you do for this condition or that condition and everybody gets the same.' "

The college is taking part in the American Board of Internal Medicine Foundation's Choosing Wisely initiative, launched in late 2011 to target overused and misused tests and procedures.

The American Medical Association has related policy that says "physicians should be cost conscious and should exercise discretion, consistent with good medical care." The AMA also supports comparative-effectiveness research to help doctors determine the superiority of competing treatments.

Avoiding trouble online

On social media, the college's brief guidance says physicians should adhere to traditional standards of patient confidentiality in this new setting and "maintain a professional demeanor in accounts that could be viewed by patients or the public."

The AMA's policy on social media, adopted in November 2010, offers similar advice but adds that physicians have a responsibility to notify colleagues of unprofessional postings and report them to authorities if no action is taken.

Pressure to include the topic in the updated manual came from younger physicians more likely to be active on sites such as Facebook, Twitter and YouTube, Dr. Hood said.

"The policy is really saying that we should use the same discretion when we have physician-patient interactions online as we do in any public space," she added. "The problem, of course, is that those boundaries are somewhat blurred more easily in the digital world. ... It's a bit easier to get into trouble."

The college's ethics manual, published as a supplement to the Jan. 3 Annals of Internal Medicine, is available at no charge on the journal's website (link).