As a pediatric intensivist, I have noticed a common refrain over the past several years during morning rounds. While presenting the case of a critically ill child, the team pauses over something as simple as whether to order a routine lab test. A trainee hesitates, citing cost. When I ask what that means (cost to the family, the hospital, or the system as a whole?), there is rarely a clear answer. The word lingers, shaping the discussion without real understanding. These moments have become familiar reminders that while “cost” has entered our daily vocabulary, few can define what it truly represents.
Across the country, medical trainees are being encouraged to practice “cost-conscious care.” The motivation is understandable. Health care spending in the U.S. now exceeds $4.5 trillion annually, approaching one-fifth of the economy. Yet the education physicians receive about health care finance is limited and inconsistent. Few medical schools teach even the basics of how money moves through the system. Terms like “fixed cost” and “variable cost” are seldom introduced, and the process of price negotiation between payers and physicians remains opaque. For those of us who later study health care administration, we learn that the logic behind medical finance is often inconsistent, irrational, and rarely aligned with the reality of clinical care or the best interests of patients.
Prices in health care are not set by supply and demand. They are the result of private negotiations that can vary widely between insurers and hospitals. The same test or therapy can cost hundreds at one facility and thousands at another. Despite this, the responsibility for cost containment is often shifted to clinicians, who are asked to be mindful of ordering tests and therapies that represent only a fraction of total health care spending. Meanwhile, insufficient scrutiny is directed toward the true drivers of cost growth, such as insurance practices, the proliferation of administrators, and the rise of multibillion-dollar technology and data vendors that profit from every transaction.
The situation becomes even more troubling when financial considerations begin to shape decisions about life-sustaining therapies. In some discussions, whether to transfer a patient to the ICU or initiate extracorporeal life support is framed as a question of “resource stewardship.” While stewardship is important, the danger lies in allowing cost to overshadow the central ethical question: Does the potential benefit to the patient outweigh the potential harm? The physician’s duty, rooted in the Hippocratic Oath, is to act in the best interest of the patient. That duty should not be compromised by pressures to protect institutional budgets.
This confusion is partly the result of information asymmetry. Trainees are taught within a system that offers little transparency about how health care finances actually work. They are encouraged to think of themselves as cost managers rather than systems engineers capable of improving the design of care itself. As noted in “The Lancet” article “Health Care in the USA: Money Has Become the Mission,” the American health care system has inverted its priorities. Financial optimization has too often replaced the moral and clinical imperatives that once defined the profession.
Compounding the problem is a distortion of evidence-based medicine. The absence of randomized controlled trial data is sometimes treated as evidence of futility, particularly for expensive diagnostics or therapies. But medicine advances not only through large trials and meta-analyses but also through the accumulation of collective wisdom, clinical mastery, and the ability to integrate evidence into the complex realities of individual patients. An immunocompromised child with multiple organ dysfunction cannot be meaningfully reduced to a line in a cost-effectiveness table. Population-level analyses, while valuable, must never substitute for clinical judgment at the bedside. When necessary, transparent, multidisciplinary discussions among bedside clinicians aiming for quorum consensus should be used to determine courses of action deemed inappropriate for a single decision-maker (think of the field of oncology’s tumor boards).
Despite appearances of sophistication, many hospital cost-cutting initiatives focus on short-term financial priorities and overlook the broader consequences of those decisions. They often fail to account for the long-term effects on patient outcomes or the complex interdependencies between clinical services that ultimately determine both quality and cost of care. Yet genuine sophistication does exist in the realm of health economics when applied thoughtfully. Sophisticated cost analyses, grounded in rigorous modeling, can illuminate where advanced diagnostics or interventions are likely to truly add value. These efforts require time, expertise, and methodological discipline, qualities rarely mirrored in the day-to-day “cost awareness” campaigns more common to the culture of corporate health care.
If the next generation of physicians is to practice true cost-conscious care, it must begin not with hesitation but with understanding. The moments on rounds when a trainee pauses over a lab order reveal more than uncertainty, they expose the complexity of a system that too often asks individuals to make moral and financial judgments without clarity or support. Rather than teaching them to internalize that burden, we should be teaching them to take the reins of a system that might one day make value visible, align incentives with patient outcomes, and embed transparency into the everyday practice of medicine. When that happens, those pauses on rounds will no longer signal confusion, but rather confidence in a system worthy of the trust we place in it.
How is cost shaping decision-making? Share in the comments.
Dr. Chris Horvat is a pediatric intensivist, clinical informatician, and learning health systems researcher in Pittsburgh, PA. His path to medicine began as a contractor in the high-purity quartz mines of western North Carolina, likely making him the only informatician who once helped extract the raw materials powering today’s digital workflows in health care. Dr. Horvat is a 2025–2026 Doximity Op-Med Fellow.
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