Integration of Choosing Wisely Materials in Case-Based Medical School Courses

From the 2022 HVPA National Conference

Ruyan Zhang BA (University of Utah School of Medicine), Nathanael Jensen BS, Lauren Donovan BS, Terrell Blei BA, Ryan Murphy MD


Nearly $1 trillion is wasted annually in U.S. healthcare expenditures and clinical decision-making is a major contributor to rising costs so great effort is expended to target and remediate behaviors of clinicians in practice. However, research suggests physician resource utilization is strongly influenced by practices to which they were exposed during training. Choosing Wisely (CW) is a campaign that promotes resource stewardship by helping physicians and patients engage in conversations about unnecessary tests and treatments.


The main objective of this study is to evaluate the impact of including CW curriculum into first-year case-based learning activities on the attitude and behavior of pre-clinical University of Utah students around resource stewardship.


As part of the Choosing Wisely STARS campaign (CW STARS), we incorporated Choosing Wisely recommendations into the pre-clinical case-based learning (CBL) curriculum to familiarize medical students with high-value care concepts. Through weekly clinical scenarios, students work in small groups to discuss cases, facilitated by faculty to promote self-directed learning using guided questions. We evaluated each CBL case and incorporated applicable CW guidelines into the discussion points for treatment, imaging, and patient centered decision-making. Ten cases were presented with integrated high-value care concepts to 125 first-year medical students. A pre-intervention survey was distributed to all students prior to starting classes to assess initial attitudes toward cost-conscious care and level of familiarity with the Choosing Wisely campaign. Another survey was distributed at the completion of the first year, after the completion of all CBL interventions. Answers to each of the survey questions were correlated to a numerical value that allowed for paired t-test statistical analysis; results were considered statistically significant at p-value < 0.05.


Integrating CW principles into the case-based curriculum at the University of Utah Medical School led to increased familiarity and exposure to high-value practices. Survey data among the 77 participants that responded showed significant differences in pre and post implementation data in three categories. First, prior to CBL changes, students only learned about high-value care through elective courses or independent learning. After intervention, almost all students had heard about the CW campaign and its purpose. Second, students were more likely to identify that the frequency of unnecessary tests and procedures in the healthcare system was “a very serious problem” compared to “a somewhat serious problem. Third, more students agreed that cost to society should be an important factor in the utilization of interventions. Overall, the implementation of CW topics into our medical school curriculum demonstrated quantitative changes in students’ attitudes surrounding resource stewardship.

Conclusions and Clinical Implications

We believe the inclusion of CW guidelines and high-value resources can help students reconcile their beliefs with evidence-based practice recommendations in encounters they will undoubtedly face in their careers. Incorporating such information into existing courses offers a method to introduce novel concepts into the expanding competencies expected of graduating medical students. This intervention offered a unique method to integrate a topic endorsed by the American Medical Association, and soon to be incorporated into standardized exams by the National Board of Medical Examiners (NBME), into a crowded pre-clinical medical curriculum. As additional competencies are expected of medical students, schools are obligated to adapt and incorporate new objectives into existing curricula in order to prepare learners.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog