Insights on Residency Training

April Edwards, MD, is the 2016-17 Chief Resident for Internal Medicine/Pediatrics program at the University of North Carolina School of Medicine.

A harsh reality I am coming to terms with, as a newly minted “pre-tending,” is that we don’t know the cost of the care we provide. There are recommendations for things like High Value Care, from organizations like the ACP. But how much do things actually cost? Certain apps and websites, like the Healthcare Bluebook, give you an idea of the cost of tests, procedures, and medications that you are ordering for your patients. But often, especially at hospitals like mine, public hospitals that serve many uninsured, under-insured, and Medicare/Medicaid patients, we encounter situations  where patients can’t afford the services and medications that they need. I often find myself turning to sites like Good Rx to get coupons for patients, but, beyond this, the reality is that I don’t know where they can get affordable care.

I live in North Carolina, and I recently had a patient with presumed Rickettsial illness who was unable to afford doxycycline. I assumed this antibiotic was so basic and simple and been marketed for such a long time that surely it had to be accessible. But he wasn’t able to afford it. So how can we help? What tools are at our disposal?

Good Rx is one. If you type in a drug name, it will show you the pharmacies near the patient’s home that have that medication; the patient can compare prices at different pharmacies in the area. You can get printable coupons; you can print a voucher for the medication. We use the old standbys of the WalMart $4 list and the Target $4 list, and many medications are on those. Other resources exist, like Formulary Search, to tell you what is preapproved by a patient’s insurance. Remember all that prior auth paperwork? There are budding apps to help you with that.

But this is one of the things that we just don’t receive any training on during medical school and residency. I wish that it doesn’t matter — that “I’ll just prescribe the Best Therapy for my patient.” But I’m realizing that is a real struggle. In real life, if the benefit of the Best Therapy is something like 0.05%, but that Best Therapy is 10 times more expensive than the next best drug, sometimes it makes sense to recommend the one that is technically inferior but affordable. Because my patient will then actually be getting treatment.

By Lilly_M [GFDL or CC BY-SA 3.0], via Wikimedia Commons

It’s hard when your best intentions are met with a roll of red tape. It’s a real issue for all of our graduates fresh from residency. We are still shiny and hopeful. We haven’t become so jaded that we don’t want to Do Good. But we could use the tools to help us accomplish that.

Post your favorite resources that help you Do Good! Help others to stop grasping in the darkness!

Residency isn’t easy. But it doesn’t have to be quite so hard. Explore NEJM Resident 360 now.