My first formal lesson on health care costs occurred one afternoon on the wards when I was a medical student. The senior doctor in charge, a silver-haired specialist known for his thoughtful approach to patient care, had assembled several students and doctors-in-training to discuss a theoretical patient with belly pain. After describing the patient’s history and physical exam, he asked what tests we might order.
One doctor-in-training proposed blood work. A fellow student suggested a urine test. Another classmate asked for abdominal X-rays.
My hand shot up. “A CAT scan,” I crowed with confidence. “I’d get a CAT scan!”
There was complete silence. Everyone turned to stare at me.
The senior doctor coughed. “That’s an awfully expensive test,” he said, a grimace appearing on his face. Another student asked him just how much a CT scan cost, and he shifted uncomfortably in his seat and shrugged. “I don’t really know,” he said, “but I do know that we can’t just think about the patient anymore.” He took a deep breath before continuing, “We are now being forced to consider costs.”
That was 20 years ago, when the managed care movement was first in the headlines. Today his lesson still rings true, as doctors continue to struggle  to reconcile cost consciousness with quality care. And doctors-to-be are not getting much help  in learning how to do so.