United States Medical Student Attitudes about High-value, Cost-conscious Care

From the 2022 HVPA National Conference

Hunter Niehus BS (Oregon Health &  Science University), Ali Gunesch BS, Anne Smeraglio MD


Over a third of Americans struggle to pay their healthcare bills, and physicians directly contribute to this financial burden when they recommend low-value tests or interventions. A movement to educate physicians about High-value, Cost-conscious Care (HVCCC) may offer a means of reducing these excessive costs. Prior studies have found that physician cost-consciousness behaviors and attitudes may be influenced by their training environment, but to our knowledge no recent studies have sought to determine the effects of life experiences prior to medical training on attitudes about HVCCC.


Administer a cross-sectional survey to describe United States medical student attitudes towards High-Value, Cost-Conscious Care (HVCCC) using a validated questionnaire, and to identify student experiences or demographic factors that may affect those attitudes.


An electronic survey was sent to all medical students at 10 US medical schools. The survey collected data on self-identified economic, educational, or healthcare access hardship, along with stage of training, career goals, and educational debt burden. Students then completed the 25-item Maastricht HVCCC Attitudes Questionnaire (MHAQ), which measures attitudes in the domains of Cost Incorporation into medical practice, High-Value Care delivery, and Perceived Drawbacks to HVCCC. Scores within each domain range from 1-4, with 2.5 representing ambivalence. The Wilcoxon signed-rank test was applied to compare mean MHAQ domain scores among a range of pre-matriculation exposures. Students also completed a free-response section to qualitatively describe their experiences with cost and value in health care, which will be analyzed and reported separately.


682 medical students responded, 62% of whom were women. 13% reported economic disadvantage, 15% educational disadvantage, and 35% reported that healthcare costs presented a moderate or greater burden to their family. Students had a neutral-to-positive attitude towards Cost Incorporation (mean 2.86 ± 0.40), a positive attitude towards High-Value care (mean 3.26 ± 0.35), and a neutral-to-reassured attitude against significant perceived drawbacks to HVCCC (mean 2.18±0.38). Men were more likely to perceive drawbacks to HVCCC than women (mean 2.24 vs 2.14, p=0.004). Students in the clinical phase of their curriculum were more likely to hold favorable attitudes towards high-value care (mean 3.29 vs 3.23, p=0.01), and perceive fewer drawbacks to HVCCC (mean 2.15 vs 2.22, p<0.001) compared to pre-clinical colleagues. There were no significant differences in attitudes based on educational, economic, or healthcare disadvantages at this interim analysis.


A substantial number of medical students report financial and educational hardships prior to matriculation, however these challenges do not appear to influence attitudes toward HVCCC. We found gender-based differences in attitudes toward HVCCC, consistent with prior literature. Students with at least one month of clinical rotations perceive fewer drawbacks to HVCCC and have more favorable attitudes to incorporating value into their medical decision making.  

Clinical Implication

Clinical experience seems to be the main driver of sculpting opinions about HVCCC. Medical educators should consider emphasizing HVCCC curricula in the clinical phase of the undergraduate medical curriculum when attitudes towards this movement are more favorable and enthusiasm may be higher. Early clinical immersion, where appropriate, may also provide students exposure to clinical scenarios that illustrate the importance of HVCCC.  

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