Teaching students and residents to practice high-value care requires a significant shift from traditional training methods.
“Historically, the culture has been that nobody was criticized for ordering more tests than necessary, but they did get criticized for leaving out a test that a supervising physician felt needed to be ordered,” said Jeff Wiese, MD, FACP, senior associate dean at Tulane University in New Orleans.
Academic hospitalists have been developing strategies to teach trainees how to balance the benefits of a medical intervention with harms and costs, in keeping with general efforts in medicine to reduce waste and improve outcomes.
Imprinting this skill, and whole outlook, on future doctors requires not only lectures and assessment but role models who provide care that optimizes outcomes without incurring unnecessary costs, according to experts.
Teaching the concept
While lowering costs is a goal of high-value care, the real concept is value. The concept of value as quality divided by cost should be explained to trainees as a broader effort to improve patient outcomes. “High-value, cost-conscious care is more than just the money component,” said Dr. Wiese. “A test that offers no additional quality to patient care is a waste, regardless of cost.”
He works to help students understand the full impact their care decisions have on patients. Unnecessary tests aren't just low in value but may also run the risk of returning a false result, taking the physician in the wrong direction. “As I would say to my students, interns, and residents, ‘Is that what you want for your patient?’” Dr. Wiese said.
This is not a concept that traditional case-based teaching has highlighted, with its focus on zebra diagnoses. “You rarely see a morning report about run-of-the-mill pneumonia, so everybody spends all their time trying to hunt down things that are really rare,” said Neel T. Shah, MD, MPP, assistant professor at Harvard Medical School in Boston and founder of Costs of Care, a nonprofit organization focused on helping clinicians provide better care at lower cost.
Advocates of high-value care have been working to correct that imbalance and provide teaching tools that focus on the value of care. ACP and the Alliance for Academic Internal Medicine collaborated to develop a high-value care curriculum for residents, including example cases (available free online).
Those resources can be incorporated into existing education programs. “Build high-value care learning objectives into all formal and informal conferences and teaching rounds,” recommended Cynthia (Daisy) Smith, MD, FACP, director of clinical program development and senior physician educator at ACP.
In addition to telling trainees about high-value care, teaching hospitalists need to show them. “I believe the topics are being increasingly discussed in the conference room,” said Dr. Smith. “The challenge is to take these discussions from the conference room to the bedside.”
That may be as simple as stressing the importance of a careful history and exam and encouraging trainees to ask themselves how a test may change their management of the patient, according to Brandon Combs, MD, FACP, assistant professor of medicine at the University of Colorado in Denver and cofounder of the Do No Harm Project, a program aimed to raise awareness around the harms of overuse. “When we're thinking about diagnoses, I like to tell my trainees to think in terms of what's most probable rather than simply what's possible,” he said.
Other high-value tips for residents include “limiting daily labs in patients who are clinically stable and removing Foley catheters as soon as possible,” Dr. Combs added.
Rather than being an occasional teaching point, high-value care should be a facet of your service's culture, according to Dr. Smith. “Promote a learning environment that supports high-value care practice, where teachers routinely ask if a proposed test will impact the patient's care plan and role model weighing potential benefits of medical interventions with harms and costs,” she said.
Hospitalists also need to make sure to practice what they're preaching. “It's all about modeling good behavior,” Dr. Shah said. Specific training for faculty may be necessary to learn how to practice and teach in a high-value mindset. “We need a more systematic approach to faculty development so that residents have high-quality role models,” Dr. Smith said.
Educational projects can be used to spread the message to both residents and practicing physicians. “Promote high-value care quality improvement projects locally, particularly ones where fellows and residents from other departments work together to reduce health care waste,” said Dr. Smith.
When a resident successfully reflects a high-value care approach, encourage the practice by pointing it out. For example, a teaching hospitalist could say, “I see that you could have gotten the CT scan, but you were thoughtful about it and it turns out the patient didn't need it. Good for you,” suggested Dr. Shah.
Assessment of high-value care skills should also be provided in a more formal setting. “They need to be routinely assessed in their ability to provide high-value care,” said Dr. Smith. “A combination of audit, feedback, and scheduled peer discussions has been very effective in the practice environment.”
This is also true for attendings, she noted. “Once you're out in the world practicing, you also need to be periodically assessed,” Dr. Smith said, adding that some hospitals use report cards or other metrics to measure utilization. “They get groups of physicians together and they look at their data as a group. Then they share best practices about how to decrease variation and practice patterns, and how to decrease utilization and improve outcomes.”
Of course, to know whether you're providing high-value care, you need to know something about the cost of care, which is one of the major challenges in providing and teaching high-value care. “It's a big black box,” said Robert L. Fogerty, MD, MPH, an ACP Member and assistant professor of medicine at Yale University in New Haven, Conn. “It's a very difficult challenge to get people to increase the value of their care without those basic tenets of knowledge.”
Opening the black box of pricing to your residents may require involvement with other hospital departments. “Get your institution's C-suite and billing department involved so that you can get real-time access to charge and cost data for your trainees,” said Dr. Smith.
Patients and families also provide important benchmarking information, Dr. Smith added. “To know whether or not you are providing high-value care, not only do you need cost data but you also need to be able to get feedback on the patient and family experience of care,” she said. “It is essential for how we measure value.” She noted that patient experience of care can be measured through patient surveys that specifically focus on perceptions of the presence and quality of high-value care discussions and decisions.
These changes won't happen overnight, the experts noted. “Shifting medical culture away from this more-is-better idea to one that promotes value is going to take some time,” Dr. Combs said. But by modeling high-value care and teaching and assessing its principles with trainees, hospitalists can help ensure today's residents become tomorrow's high-value champions.
“It's not just a new tool in our toolbox,” Dr. Fogerty said, “It's a new way to think about all of the tools that we would use.”