High-Value, Cost Conscious Care in Medical Education
Brandes, Eileen R.
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CitationBrandes, Eileen R. 2018. High-Value, Cost Conscious Care in Medical Education. Doctoral dissertation, Harvard Medical School.
AbstractPurpose: Healthcare costs represent 18% of the GDP and are continuing to rise. A major contributor is healthcare waste, an important component of which is the overuse and misuse of diagnostic testing and treatment. A recent approach to this problem is the promotion of the concept of High Value Care (HVC), i.e. healthcare that provides the greatest benefit relative to cost and harm. Although effecting a culture change about HVC has become a major priority in medical education, it is currently unknown to what extent HVC has permeated the curriculum of medical school and the clinical experiences of medical students.
Methods: A web-based survey of 20 questions was developed to compare exposure and attitudes of medical students and residents to HVC. The survey was distributed to a random sample of 1000 second year medical students (M2), 1000 fourth year medical students (M4) and 500 PGY2 and 500 PGY3 internal medicine residents (PGY) who are members of the American College of Physicians.
Results: We received 479 completed questionnaires, yielding a 16% response rate, which included responses from students and residents attending or having graduated from 144 allopathic and osteopathic medical schools. Overall, 76% of respondents indicated that they had been introduced to the concept of HVC at some point during their education or training. This percentage increased over the course of training (61% of M2, 79% of M4 and 88% of PGY; p<0.05). However, only 29% of all respondents reported that they were either very or moderately familiar with HVC. At all stages of training, “fear of missing something” was felt to be the most important factor contributing to the administration of relevant but unnecessary tests, followed by “wanting to be as thorough as possible.” There was a significant decrease over the course of training in considering “fear of a negative evaluation for not being thorough” as a major driving factor in administering a relevant, yet unnecessary test (45% of M2, 31% of M4 and 23% of PGY) (p<0.05). Of those exposed to HVC, trainees with clinical clerkship experience (i.e. M4 and PGY) reported the highest likelihood of exposure to HVC during their Internal Medicine Clerkship (91% of M4, 65% of PGY) followed by Family Medicine/Primary Care (71% of M4, 38% of PGY); all other clerkships had 44% (M4) and 11% (PGY) exposure or less. All groups reported that “lack of information about the cost of a test or treatment” was the most significant barrier to learning about HVC.
Conclusions: Although HVC exposure increases during training, barriers remain to both learning about and practicing HVC. There is also a wide variation in exposure to HVC across different medical school clerkships.
Citable link to this pagehttp://nrs.harvard.edu/urn-3:HUL.InstRepos:41973480