From the 2024 HVPA National Conference
Anuradha Haridhas BA (Wright State University Boonshoft School of Medicine), Carson Clark BS, Isabella Benintendi BS, Elizabeth Zinn BS, Amanda Bell MD, Amanda Wade BA, Patty Carney PhD, Anne Smeraglio MD
Background:
High value care (HVC) considers cost:benefit ratios in selecting diagnostic test and treatment options and drives optimal, cost-effective patient care. Low value care (LVC) reflects wasteful healthcare decisions. The way 3rd and 4th year medical students are exposed to this content during clinical rotations can have lasting impacts on their HVC behaviors in practice.
Objective:
Assess 3rd and 4th year medical students’ exposure to HVC and LVC role modeling from attendings and residents/fellows during clinical rotations.
Methods:
A cross sectional survey study was distributed to 3rd and 4th year medical students at 11 medical schools nationwide. The previously validated1 survey asked students about their observations of HCV and LVC during their last clinical rotation: who they saw exhibiting those behaviors, and how often they saw those behaviors. Descriptive statistics evaluated HVC and LVC role modeling by level of training: attendings vs. residents/fellows. Chi squared or Fishers Exact tests were used to determine differences across training levels.
Results:
Of the 2,915 medical students invited to the study, 474 opened the study, and 402 completed the study. Of the behaviors surveyed, HVC was observed by students “often” by 4.7-44.4% of students, depending on the domain. LVC behaviors were observed “often” by <1%-25% of students. Regarding cost conscious behaviors, attendings were more likely to seek cost effective data to inform their clinical decision making (p <0.001), initiate a conversation about costs of care (p <0.001), and discuss costs of care with other healthcare members of the team (p <0.001) when compared with residents/fellows. Regarding potentially wasteful role modeling behaviors, attendings were less likely than residents/fellows to order a more expensive test/treatment because the patient requests it (p <0.048), less likely to order numerous tests all at once rather than waiting for initial screening test results (p <0.039), and repeat tests rather than attempt to obtain recently performed test results (p <0.001).
Conclusion:
Overall, medical students reported inconsistent modeling of HVC behavior during their clinical training, suggesting there is substantial room for additional exposure and education in HVC concepts within clinical rotations. Attendings modeled HVC concepts more frequently than resident/fellows, while residents/fellows modeled LVC more than attendings. This difference could be attributed to attendings’ longer training time, or more comfort with assuming risk associated with forgoing repetitive diagnostic testing. The results also bring into question the adequacy of HVC education in graduate medical education. Future studies could evaluate specific ways in which HVC concepts are passed on in training as well as identify barriers to HVC implementation in residency and fellowship.
Clinical Implications:
Medical students’ report of HVC and LVC modeling suggests further faculty development and resident/fellow education is needed in HVC practices, particularly at the graduate medical education level in order to optimize healthcare costs and maximize benefit to patients.
References:
- Leep Hunderfund, Andrea N. MD, MHPE; Dyrbye, Liselotte N. MD, MHPE; Starr, Stephanie