In 2013, Costs of Care and the ABIM Foundation named winners of the first Teaching Value and Choosing Wisely competition to recognize medical educators promoting high-value care by reducing overuse in health care.
Dr. Robert Fogerty, a hospitalist and associate professor at Yale School of Medicine, was recognized for creating “I-CARE” (Interactive Cost-Awareness Resident Exercise). This exercise engages faculty and trainees in a friendly competition to create effective, lower cost care plans using traditional Morning Report structure and institutional charge data.
“Internal Medicine residency is a short time where the primary goal is for physicians to learn how to practice medicine efficiently and safely, so there is a lot that is expected in a few years,” Dr. Fogerty said. “Residents don’t receive training about the financial implications of treatment choices, so we wanted to include cost-awareness education without displacing anything else in the curriculum.”
As a cancer patient while in college, Dr. Fogerty had to face financial realities of chemotherapy while on a student budget. He had to delay medical school, in part, to dig out of a financial hole that resulted from getting well again.
I-CARE is a program through which residents work through a test case to determine whether their diagnosis is right or wrong—and it goes one step further to include how much the treatment ultimately cost. At Yale, this includes first-, second- and third-year students as well as faculty. The “winner” is the group that gets the diagnosis right while spending the least amount of money.
Since winning the Teaching Value and Choosing Wisely competition, Dr. Fogerty has collaborated with many physicians across the country and in Canada to expand I-CARE to other medical schools, leading to a series of multi-site competitions resulting in an “I-CARE world champion.”
Yale also encourages chief residents to run the sessions locally, which creates its own source of pride in letting them customize the competition and develop their leadership skills.
“We are gamifying this part of medical education,” Dr. Fogerty said. “We know that physicians are competitive by nature, so this has been successful. We want to keep I-CARE current, fresh and, of course, accurate.”
He has worked with the New England Journal of Medicine for permission to use articles as references for the educational exercise, and the journal invited Dr. Fogerty to publish an example of a case work-up last year.
In addition to I-CARE, Dr. Fogerty is working on more ways to reduce unnecessary services, improve quality and get patients appropriate care faster. He built on existing criteria hardwired in his system’s electronic health record to measure heart rate, respiration rate, white blood cell count, temperature, renal function and systolic blood pressure to generate an alert for the rapid response team if a patient is sick. He is also mentoring a resident’s project into the cost for ophthalmology and a fellow’s project looking into heart medications in Connecticut to identify unnecessary services and increase cost transparency.
“I want to work on making complex things simple,” he said. “With Choosing Wisely and the ‘five questions’ we are not going to tell clinicians how to practice, just to think about what we might not need and how the medical profession can overcome this challenge.”