From the 2021 HVPAA National Conference
Rebecca Kowalski (University of Virginia School of Medicine), Christopher Moore, Glenn Moulder, Andrew Parsons
Unnecessary test and treatments are a major driver of low-value care. These clinician-controlled wasteful practices have an estimated total annual cost to the US healthcare system of $75.7 to $101.2 billion (Shrank et al. JAMA 2019). They also lead to increased financial burdens for patients, iatrogenic harm, and can trigger additional testing via cascades (Korenstein et al. JAMA Intern Med 2018). A common scenario that clinicians encounter that leads to unnecessary testing occurs when patients request inappropriate tests or treatments. Almost half of physicians report at least one patient request per week for an unnecessary test or treatment (Choosing Wisely 2014). Lack of training in how best to navigate these requests can lead clinicians to defer to patient wishes, increasing costs and potentially causing patient harm. We describe a formalized initiative to teach clinicians in training how to handle these scenarios using a novel communication tool.
To provide medical students with a communication tool to navigate patient conversations in response to requests for nonindicated tests or treatments.
The TOO PRICEY tool (Figure 1) was developed using a student-led, iterative approach with expert faculty following review of the available literature on patient-provider value conversations. TOO PRICEY has two temporal components: TOO refers to the preparation the clinician should do prior to the conversation, and PRICEY serves as an outline of the conversation itself. The preparation elements include Test/Treatment (know the characteristics of the test or treatment), Options (consider less invasive, lower risk options), and Open (keep an open mind about patient’s concerns and requests). The conversational elements include Perspective (seek patient’s perspective), Reassure (convey confidence that concerning conditions are effectively ruled out), Incidental/Iatrogenic (discuss risk of incidental findings and adverse effects), Cost, Empathize, You (return conversation to patient). The tool was taught during a dedicated two-hour session within the pre-clerkship clinical skills course, in which a didactic presentation was followed by a hands-on workshop that included two practice scenarios: patient with headache requesting an MRI and patient requesting antibiotics for a viral infection.
One-hundred and fifty-three students participated in the workshop as part of the required pre-clerkship curriculum; pre- and post-session survey response rates were 98% and 95%, respectively. Prior to the workshop, 43% of students felt somewhat or extremely comfortable having conversations with patients about their requests for nonindicated tests or treatments; following the workshop, this percentage doubled to 84%. On the whole, 75% of students felt the quality of the workshop was “Good” or “Very Good.”
The TOO PRICEY communication tool and associated hands-on workshop increased medical students’ confidence in navigating conversations with patients following requests for non-indicated tests and treatments.
This tool provides a framework to teach future clinicians how to elicit and address patient concerns regarding unnecessary tests and treatments, promoting shared decisions on diagnostic and therapeutic management. Having these conversations with patients is an important step towards reducing low-value care. We suggest training for such conversations begin early in medical training consistent with other frameworks such as GOTMeDS (Kumar et al. Am J Med 2016), a patient-centered tool to tackle excessive medication costs.