Shaping Medical Student Attitudes of High-Value Care: In Their Own Words

From the 2023 HVPA National Conference

Ali Gunesch B.S. (Oregon Health & Science University), Hunter Niehus M.D., Patty Carney Ph.D.,  Andrea Smeraglio M.D.

As medical costs in the U.S. continue to rise, it is increasingly important for medical schools to educate students on High-Value Cost-Conscious Care (HVCCC) practices. However, medical students have varying attitudes regarding these principles and their willingness to implement them into practice. These attitudes have been shown to differ based on timing of exposure to HVCCC topics and experiences with clinical mentors, but little work has been done to understand what students themselves believe have shaped their attitudes.

To more richly understand the factors that students perceive as shaping their attitudes towards HVCCC using a multi-institutional survey.

A Qualtrics survey was emailed to students at nine U.S. medical schools. Students completed the Maastricht HVCCC Attitude Questionnaire (MHAQ) which measures attitudes around high-value care, cost incorporation, and perceived drawbacks on a 4-point Likert scale. Students were then asked to complete two optional, free-response questions.

“What experiences have shaped your attitude about the physician’s role in containing health care costs?”
“How has your attitude towards the physician’s role in containing health care costs changed since starting medical school?”

MHAQ scores were calculated and respondents were sorted into tertiles representing high, moderate, and low favorability toward HVCCC. The free text responses from the high and low tertiles based on MHAQ scores underwent qualitative content analysis and were compared for differences.

682 medical students responded to the survey, 454 completed the open-ended questions. Content analysis identified 17 types of experiences impacting student attitudes towards HVCCC, ranging from personal experiences with healthcare, to clinical rotations. 45 students identified medical school curriculum as an impactful experience, these students were more likely to hold a positive attitude towards HVCCC (32/45 [71%] in the high MHAQ tertile). There were no other clear associations between type of experience and HVCCC attitude. Respondents also expressed 23 distinct beliefs about HVCCC and the healthcare system overall. 56 students felt that costs can lead to financial hardship or prevent patients from seeking care, while 34 identified concerns about wasteful clinical practices; both groups were more likely to hold a positive attitude towards HVCCC (37/56 [66%] in the high MHAQ tertile and 22/34 [65%] in the high MHAQ tertile, respectively). 48 students cited concerns about for-profit medical industries or systemic inefficiencies, and 18 expressed worries that HVCCC practices can lead to inappropriately limited care or harm underserved populations; these groups were more likely to hold a less favorable attitude toward HVCCC (36/48 [75%] in the low MHAQ tertile and 16/18 [88%] in the low MHAQ tertile, respectively).

Medical student attitudes towards HVCCC are shaped both positively and negatively by a diverse combination of personal, professional, and educational experiences; however, exposure to HVCCC through curriculum was a key theme expressed primarily by students with more favorable attitudes towards HVCCC. HVCCC attitudes are also influenced by beliefs about the medical system. Students with favorable attitudes tended to believe that health care costs can cause harm and that physician-generated waste contributes to this. Students with less favorable attitudes tended to identify systems-level problems driving costs, and cite fears that HVCCC may selectively harm underserved populations.

Clinical Implications:
As medical schools develop further curriculum on HVCCC, they can tailor their content to more effectively address student-specific concerns about these topics, which may promote increased adoption of HVCCC practices in future providers.

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.

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