The Trickle Down Effect: The Attending’s Role in Resident Lab Ordering Behavior

From the 2018 HVPAA National Conference

Rachna Rawal (St. Louis University), Oluwasayo Adeyemo (St. Louis University), Paul Kunnath (St. Louis University), Hala Saad (St. Louis University), Jennifer Schmidt (St. Louis University)


Unnecessary laboratory orders are a well-known contributor to healthcare cost. Our residents identified “fear of attending” as a reason to order labs. This project focused on educating attending physicians on high-value care and promoting resident-attending discussions.


1. Promote attending physician awareness of role in high-value care

2. Analyze resident perception of the attending

3. Improve the attending and resident relationship


Data was collected via anonymous pre and post-intervention survey (designed by study team). Participants included resident and attending physicians on inpatient Medicine service. Multiple interventions occurred over a 16-week period. Interventions included presentations at the monthly hospitalist meeting (included resident lab-ordering practices and resident perceptions of attendings). Electronic requests asked attendings to voluntarily submit a message or photo of support for the project; messages were shared with residents via email and team-room poster. An attending project champion was identified and emailed attendings on service with reminders to discuss lab ordering with their teams.


Pre-intervention, 70% of residents reported worry about repercussion from attending if daily labs were not ordered; this decreased to 41% post-intervention. Residents receiving “pushback” from attendings for not ordering daily labs increased from 25% to 54% (statistically significant, p<0.05). Survey results listed in Table 1.


Our data shows a discrepancy in the perception of mindful lab ordering between resident and attending physicians, with attendings perceiving they discuss labs more often compared to the resident perception. While this difference decreased, it remained. Attendings have a higher perception of attending-initiated discussions and a lower perception of resident-initiate discussion than do residents. There has been an increase in resident reported resident-attending and overall team discussion of lab ordering. Interestingly, more residents have reported receiving pushback for not ordering daily labs from attendings. This may suggest that attendings are more resistant to mindful lab ordering than they perceive or may reflect increased effort by residents to change lab ordering practices. Despite pushback, fewer residents fear attendings’ repercussion. Our data suggests that we have started a cultural shift at both attending and residents levels but additional work remains.

Implications for the Patient

Medicine’s hierarchical structure results in attending physicians’ strong influence on resident ordering practices. It is then crucial for attending physicians to promote high-value, cost-conscious care through team discussion and a positive learning environment.

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