Student-driven integration of value-based care and building trust into evidence-based medicine curriculum for first-year medical students

From the 2023 HVPA National Conference

Elina Kurkurina MPH (Frank H Netter MD School of Medicine at Quinnipiac University), Kathleen Mulligan BA, Alexander Mass BS, Brendan Rooney BS, Rahul Anand MD

Overuse of medical care is a common, costly problem; estimates show approximately twenty-five percent of U.S. medical spending is wasteful. Medical students often learn such wasteful ordering and patterns of clinical reasoning that lead to low-value care. These wasteful behaviors remain as trainees progress through their careers, perpetuating overuse. It is thus imperative to teach value-based care principles in medical education. To address this, first-year medical students worked with their faculty advisor to create a student-led session on value-based care and building trust for first-year medical students at their institution.

To create a didactic session that provides first-year medical students with a framework of value-based care and strategies to build trust when discussing value with patients and colleagues.

We developed a two-hour interactive session that included explicit teaching on value-based care, Choosing Wisely guidelines, and strategies to build trust when discussing value-based recommendations with patients and colleagues. Kolb’s learning cycle was used as a conceptual framework for session design. The session included why value and trust matter to students and patients, what frameworks to use for value and building trust, and how Choosing Wisely guidelines are created. Students also participated in role-play scenarios based on Choosing Wisely guidelines to practice having value conversations. Students then engaged in group reflection to reinforce trust-building communication skills and clarify guideline understanding.

A mixed methods approach was used for data analysis. Students rated their knowledge of the Choosing Wisely program, familiarity with value-based medicine, and confidence in discussing value-based care with patients and colleagues on a five-point Likert scale. We conducted an independent t-test to compare pre- and post-survey responses to these items. Students were also asked to define value-based care. Two team members independently coded these free-text responses; a third team member reconciled discordant coding.

85 students completed the pre-survey and 71 students completed the post-survey. Following the session, students had higher self-reported knowledge of Choosing Wisely (1.65 vs 4.04 out of 5) and value-based care (2.27 vs 4.27 out of 5); as well as increased confidence in having value discussions with patients (2.38 vs 4.21 out of 5) and colleagues (2.39 vs 4.13 out of 5). All improvements were statistically significant (p-values <0.01).

Prior to the session, students commonly believed that value-based care was based on patients’ and physicians’ personal beliefs, values, and goals (31.8% of students); considered monetary and other costs of tests and treatments (20.0% of students); and/or focused on providing care that would produce the best outcomes for patients (37.6% of students). Relatively few students (14.1%) included consideration of both costs and outcomes in their pre-session definitions of value. Following the session, most students (87.3%) defined value-based care as care that involves careful consideration of both the costs and outcomes of tests and treatments.

Prior to explicit teaching, most first-year medical students were unable to provide a complete definition of value-based care. A student-led session on value was sufficient to increase medical students’ self-perceived and actual knowledge, as well as their confidence in having value discussions with patients and colleagues.

Clinical Implications:
By increasing medical students’ knowledge of value-based care principles and confidence in having value conversations, a peer-led session on value-based care may allow medical students to implement value-based reasoning and communication skills early in their medical careers.

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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