Teaching Clinical Decision Making and Cost-Effectiveness in Medical School: A Simulated Back Pain Case

Abstract

To practice in the 21st Century, medical students must learn to practice evidence-based medicine in a cost-effective manner. As part of UCLA’s longitudinal Doctoring curriculum, medical students learn to practice evidence-based medicine in a cost-effective manner using a number of simulated cases. Medical students meet every two weeks throughout the academic year in small groups of 8 students with two faculty tutors. The small groups function like group practices in which they diagnose and treat standardized patients with common clinical diagnoses. For the low back pain case, students critically review the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines on Acute Low Back Problems and clinical trials from the primary literature. A 45 year-old male teacher (standardized patient) presents to the student group practice with acute low back pain. The faculty tutors help the students generate a focused history that has high positive and negative predictive value. Two students conduct a focused history and physical exam on the patient in front of the small group. When the patient requests a spine x-ray, the students explore ways to negotiate with patients to discourage unnecessary costly testing. Two weeks later, the patient wants to know if he should see a chiropractor or physical therapist. The students discuss the costs and benefits of these interventions with the patient. They apply rules of evidence-based medicine and learn to deal with uncertainty and the need to be cost-effective in how they order tests and prescribe treatments.