From the 2024 HVPA National Conference
Scott Giberson B.S. (University of North Carolina School of Medicine), Jill Stachowski B.S. (Penn State College of Medicine), Casey Olm-Shipman M.D., M.S., Amanda Wade B.A., Patty Carney Ph.D., M.S., Anne Smeraglio M.D.
Background:
Role-modeling high-value care (HVC) behaviors to trainees may lead to improved cost-conscious care in the future. Given the wide range of medical specialties, understanding HVC practice differences among diverse clinical specialties is important.
Objective:
To investigate how HVC is seen in practice by medical students completing clinical rotations in each medical specialty.
Methods:
Third and fourth-year medical students from eleven U.S. medical schools that were members of the Students and Trainees Advocating for Resource Stewardship (STARS) program were sampled. Students were invited to complete an online survey regarding practices observed during their clinical rotation. The survey measured thirteen variables, including seven cost-conscious role modeling behaviors and five wasteful role modeling behaviors. Analyses were stratified according to core specialty (internal medicine, pediatrics, psychiatry, obstetrics and gynecology, and surgery), continuity-based (family medicine, neurology, and rehabilitation medicine) or procedural-oriented (anesthesiology, dermatology, diagnostic radiology, emergency medicine, ophthalmology, otolaryngology, pathology, radiology, thoracic surgery, and vascular surgery). A final “other” category was assigned for those that did not specify the rotation.
Results
Among the 2,915 medical students who received the invitation to participate, 402 (13.8%) provided some survey data.
Cost-conscious role modeling behaviors were observed across all clinical rotations sometimes or often (ranging from between 52.9% – 70.5% of respondents) in all HVC behavior variables (Figure 1A). Potentially wasteful role modeling behaviors were sometimes or often observed only 5% to 14.3% of the time (Figure 1B).
Students observed internal medicine attendings displaying cost-conscious behaviors most often, answering sometimes or often to the questions 67.6% of the time (Table 1A). Attending surgeons were the least likely to display cost-conscious behaviors at 47.3%. Interestingly, these consistent differences were not reflected in wasteful behavior categories, as no significant differences were found except for a single question (<12.5% p=0.015) (Table 3).
Conclusions
This study shows that HVC behaviors were modeled as “sometimes or often” 47% to 67% of the time, reflecting a low overall frequency of positive modeling behaviors as perceived by students. More specifically, surgery and psychiatry attendings tended to lag in their perceived modeling behaviors. Conversely, all specialties exhibited wasteful behavior at a roughly similar rate, one that is substantially lower than the rate observed for cost-conscious behaviors.
Clinical Implications
Our results show that not only do all specialties have room for improvement in HVC role modeling, but adherence to HVC in the clinical learning environment seems to be specialty specific. Psychiatry and surgery were lower in modeling of cost-conscious behaviors, comparatively, indicating that a focus on HVC is not standardized nor widely adopted across specialties. This creates varying levels of burden for patients navigating different specialties and health systems where these specialties play key roles. Further work should be done to explore why these differences exist, and key areas for targeted interventions.