Knowledge and attitudes on value-based healthcare among a national group of physicians-in-training

From the 2018 HVPAA National Conference

Kencee Graves (University of Utah School of Medicine), Christopher King (University of Colorado School of Medicine), Kshitij Thakur (Crozer-Chester Medical Center), Deepak Agarwal (UTSW), Pamela Johnson (Jhu), Giri Andukuri (Creighton University Medical Center), Robert Fogerty (Yale), Remus Popa (University of California Riverside)


A physician’s ability to practice cost-conscious care is linked to the residency program from which they graduate, yet there is little information regarding what physicians-in-training nationally understand about value. We evaluated the knowledge and attitudes of a national cohort of residents and fellows from a variety of training programs.


To determine knowledge and attitudes on health care value and costs among resident and fellow trainees in the United States and use the information to determine the need for a High Value Practice educational initiative for physicians-in-training.


In July 2016, a web-based survey was administered to 77 residents and fellows, representing more than 50 institutions, to evaluate their understanding of cost and value principles. All but one participant responded to the survey. The survey was developed using readily available educational content for value-based healthcare, and included questions to gauge understanding of healthcare costs and attitudes towards value based behaviors. Demographic information, such as name, specialty and training level, was collected from respondents. All data was de-identified for analysis.


The trainees represented eleven specialties, predominantly in university-based programs, with 15% from community based programs. Most were residents (63/76; 83%), with the rest being fellows. Very few had education in value or quality in healthcare during medical school (5/76, 7%) and less than half (35/76, 46%) had such training during residency. Interestingly, the majority (55/76, 72%) had participated in a quality, patient safety or cost reduction project. Less than half of respondents identified the correct definitions of costs, charges or price in healthcare. Only 14% agreed or strongly agreed that they were comfortable with incorporating cost into medical decisions, and 4% agreed or strongly agreed that they had access to information about costs. However, the majority felt that it was important to factor information about cost into patient care and that physicians should know the costs of care.


Physicians are responsible for a large part of healthcare costs, and are well positioned to have a positive impact on value-based healthcare. However, little is known about how physicians-in-training understand cost and value. This study evaluated the knowledge and attitudes of a national sample of resident and fellow physicians, and provides a robust cross section to evaluate high-value concepts. While the majority of participants felt that cost should be factored into patient decisions, very few felt comfortable with this or felt that they had access to this information. Our results demonstrate a need for a widely available curriculum focused on High Value Practice. One caveat about the participants in this survey is that they are a self-selected and motivated group to learn and be leaders in health care value; therefore, we estimate that the lack of understanding of health value is far bigger than what we demonstrate.

Implications for the Patient

Physician practice patterns are highly influenced by their training program; however, few physicians in training have access to a curriculum focused on how to cultivate High Value Practice. Our survey highlights the need to create an effective curriculum to serve future trainees and patients.

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