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Effect of cost exposure on medical students’ preferred mammography screening strategies: a randomized comparison

Clarice Nguyen (UCSF), George Sawaya (UCSF), Ari Hoffman (UCSF)


Many high value care educational interventions have focused on shaping clinical decision-making for individual patients. Few interventions have investigated how students integrate cost information into clinical recommendations for populations.


To examine the independent role of exposure to cost information on medical students’ selection of a breast cancer screening strategy from both population and individual perspective in order to inform the development of high-value care curricula in undergraduate medical education.


In 2017, third-year medical students at UCSF participated in a small group on expected benefits and harms of mammography. Those in even-numbered groups viewed estimated total costs of different breast cancer screening strategies (Table). All students completed an online survey in which they selected a screening strategy from different perspectives: from a publicly funded program and an individual patient. The intervention was conducted for two cohorts of third-year students, one early and one advanced group. We used the chi-square test for independence and chi-square test for trend to compare percentages.


In total, 322 students were randomized, and 267 completed the online survey (83% response rate). Of those who completed the survey, 53% of early third-year students (n=134) and 52% of advanced third-year students (n=133) were in the cost exposure group. Among both early and advanced third-year students, those in the cost exposure group selected significantly less intensive and less costly screening strategies for publicly funded programs compared with those in the control group (p<0.005); strategies they would choose for an individual patient, however, were not affected by cost exposure (Figure). When stratified by cohort, we found similar results (data not shown).


Students tend to weigh cost considerations more heavily when making decisions about populations, rather than individual hypothetical patients. Our findings are consistent with literature on the variable impacts of passive cost exposure on physicians’ ordering behavior, emphasizing the complexity of incorporating costs in individual patient care. We suggest that it may be easier for students to relate cost considerations to populations, and initial curricular activities be framed from this perspective; building on this foundation, subsequent high value care activities can focus on individual patient care. Moreover, ethical tensions may arise when moving between individual patient and population perspectives, and curricula may need to incorporate an explicit discussion of these tensions.

Implications for the Patient

High-value care curricula will need to bridge the gap between cost consciousness at the population and individual levels, assuring that students are able to translate public health cost considerations directly into patient care.