By PAULINE W. CHEN, M.D.

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.

But one nonprofit organization, Costs of Care, and the young doctor who created it are determined to change that.

Over the last two years, Dr. Neel Shah, a senior resident in obstetrics and gynecology at Brigham and Women’s Hospital in Boston, has been collaborating with medical educators and health care economists at Harvard Medical School and at the Pritzker School of Medicine at the University of Chicago to create a series of videos and educational materials designed to help medical students and doctors-in-training learn to make clinical decisions that optimize both quality of care and cost. With support from the American Board of Internal Medicine, these educational modules, called the Teaching Value Project, could represent a significant breakthrough in how medical students learn to be conscious of costs.

The patchwork of payment patterns that mark the American medical system makes it particularly difficult to teach young doctors. Net costs for treatments and medications vary depending on region, payer and even specific hospitals, so medical students and trainees often end up learning what is relevant only to their particular workplace. They might learn to prescribe a certain drug for diabetes because it is cheaper in their hospital formulary, only to discover later that the reverse is true in a different hospital or after policies have changed.

“When learning is haphazard like this, it’s hard for young doctors to see the entire picture,” said Dr. Vineet Arora, an assistant dean at Pritzker who is working on the Teaching Value Project.

Cost variations aside, it can also be a challenge simply to get hold of precise costs for patients. Dr. Shah recalls one woman who refused to get a potentially lifesaving ultrasound until she knew how much it would cost her. Her doctors and nurses “sweated out every minute,” concerned she would collapse at any moment, said Dr. Shah, before finally hunting down a figure later that afternoon, and the patient consented to paying the $600 cost.

The Teaching Value Project uses a rough pricing hierarchy rather than exact dollar figures to gauge costs, similar to the approach at well-known restaurant or travel search sites, which helps young doctors avoid getting mired in price variations and hairsplitting details. When combined with the project’s lessons on common cost errors that doctors make, the pricing hierarchy can bring clarity to clinical decisions.

For example, a young doctor might plan on ordering an ultrasound of the heart, or an echocardiogram, for an otherwise stable patient in the hospital because the wait for inpatients is shorter. But if that doctor also knows that echocardiograms are much less expensive when administered to outpatients, he or she might instead decide to wait and order it after discharge.

Similarly, a team of trainees might believe they are being cost-conscious by debating whether to get a battery of moderately expensive tests for a patient in the intensive care unit. But then they might learn that the time they are devoting to the debate is actually costing more than the tests themselves because of the expense of keeping the patient in an I.C.U. bed even a few extra hours.

“Zagat has figured it out,” Dr. Shah said. “Knowing whether it’s one, two or three dollar signs can be enough to influence behavior.”

The group recently posted an introductory video, a tongue-in-cheek look at what hotels would be like if they were run like hospitals. At the “Hotel Hôpital,” prices are never listed; concierges order expensive cabs pre-emptively, or “prophylactically,” even if you don’t need one; and no one working in the back office can decipher your surprise $20,000 hotel bill.

The group expects to complete its first full Teaching Value module this summer, with more planned over the next few years. It also hopes to collaborate with professional medical organizations to help raise cost consciousness among more established practicing physicians.

All involved are quick to acknowledge that as appealing as the approach may be, the Teaching Value Project represents only a beginning for medical students and trainees. “Our goal isn’t for them to master the entire topic before graduating,” Dr. Arora said. “It’s to get them thinking about how to integrate cost consciousness into practice.”

Dr. Shah added: “At the end of the day, what we are talking about is spending our patients’ money in a way that is both ethical and pragmatic. To do that, we will all need to create a culture where it becomes awkward not to think about cost.”