Push to Provide High-Value Care Takes Root in Medical Training

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Editor’s Note: Throughout 2016, AAMCNews will explore how medical schools and teaching hospitals are educating the next generation of physicians in an environment of discovery and innovation.

A man in his 50s is scheduled for a medical procedure for a painful umbilical hernia. Even though he is otherwise healthy, he has a distant history of asthma, so his physicians order a chest X-ray.

That X-ray suggests a lung abnormality so the hernia operation is cancelled. During follow up with a CT scan, the lung abnormality turns out to be a false alarm, but the scan finds a spot on the adrenal gland. To sort that out, the patient receives another CT scan, which shows the spot is benign. Months later and with his medical costs mounting, the patient finally gets the hernia operation.

According to Brandon Combs, MD, an assistant professor in the Division of General Internal Medicine at the University of Colorado School of Medicine, this true-life story is emblematic of the challenges of delivering high-value, cost-conscious health care. “This whole course of events is not uncommon,” he said.

In response, Combs, along with Tanner Caverly, MD, MPH, now a fellow and clinical lecturer at the University of Michigan Medical School, decided to turn such cases into teaching tools. In 2012, they officially launched the Do No Harm Project, which uses clinical vignettes to raise awareness about medical tests and procedures that may not be necessary and spark conversations about high-value care.

“We think this whole process of talking and writing about medical overuse can change behavior and lead to higher-value, higher-quality care.”

 Brandon Combs, MD, University of Colorado School of Medicine

The Do No Harm Project began at the Denver Veteran Affairs Medical Center, a teaching site affiliated with the University of Colorado. Once a month, all trainees there have an opportunity to submit medical overuse stories to the Do No Harm story repository, now nearing 100 submissions. Trainees who participate receive a day free from clinical duty to write their stories. Today, Do No Harm is integrated into two longitudinal clerkships at the University of Colorado. The program also inspired the Teachable Moments series in JAMA Internal Medicine and, with the support of the Lown Institute, is encouraging medical schools across the country to launch similar efforts.

“We think this whole process of talking and writing about medical overuse can change behavior and lead to higher-value, higher-quality care,” Combs said. “This is where the narrative meets the science.”

The Do No Harm Project is part of a growing movement to educate medical students and residents better about high-value care and cost-conscious care. While growth in per capita health care spending slowed in recent years, U.S. health care spending still increased 5.3 percent in 2014 to $3 trillion, according to new data published in January in Health Affairs. And because physicians have a singular role in ensuring such costs align with high-value care—care that balances benefits, costs, and harms—innovative curricula and efforts are popping up across the country.

At Mayo Medical School, education in delivering high-value care is part of the new Science of Health Care Delivery curriculum. Stephanie Starr, MD, co-director of the new curriculum, described this education as the “third science” after basic and clinical sciences.

“There’s a gap between what health care professionals need to understand beyond basic and clinical science,” Starr said. “Without that third science, the other two won’t be as impactful as they could be.”

The required curriculum, which began this year for first-year students at the college’s Rochester, Minn., campus, is spread over four years and also covers health care policy, economics, and technology; leadership; person-centered care; team-based care; and population-centered care. Starr said students are especially eager to hear from practicing clinicians on how they balance the complexities of delivering higher-quality, lower-cost care, when the definition of value can differ wildly depending on the stakeholder.

“There’s nothing black and white about medicine,” Starr said. “But it’s clear that folks need to understand this challenge early in their training.”

At Vanderbilt University Medical Center, residents are taking the lead in dismantling the myth that more care is better. Meghan Kapp, MD, MS, resident physician in the Department of Pathology, and Wade Iams, MD, chief medical resident, are co-chairs of a resident-led Choosing Wisely initiative. Launched in 2012 by the American Board of Internal Medicine Foundation and Consumer Reports, Choosing Wisely aims to reduce unnecessary medical tests and procedures. At Vanderbilt, Kapp, Iams, and their fellow residents decided to zero in on one particular Choosing Wisely recommendation: decreasing daily laboratory tests.

Iams said that in addition to institutional data showing that daily blood draws could be safely reduced by up to 40 percent, house staff could easily rally around this goal—it saves time and prevents unnecessary pain and cost for the patient. However, instead of taking a top-down approach, the residents used education and data feedback to spur culture change. They refrained from identifying what constitutes a “necessary” lab and instead encouraged staff to think more critically about a test’s necessity within the unique context of each patient, Kapp said.

Under the initiative, which began at Vanderbilt in 2014, patients receiving daily labs decreased from upward of 95 percent to about 60 percent. “It definitely makes me think more upstream—about why I’m doing what I’m doing,” Iams said. “Ultimately, it comes down to the individual patient and what matters most to him or her.”

For Nilay Patel, MD, a cardiology fellow at Massachusetts General Hospital (MGH), it was clear during his early training that cost was a mounting concern, and yet he wasn’t receiving any specific education on how to be a “better steward of our resources,” he said. In response, during his internal medicine residency at MGH in 2013, he sent out a short survey to fellow residents. He discovered that while many thought about cost and value on a daily basis, few felt knowledgeable on the topic.

In 2014, Patel received an AAMC Clinical Care Innovation Challenge Pilot Award to develop a high-value care curriculum for internal medicine residents that included lectures, small-group conferences, and one-on-one teaching with faculty advisers, as well as an awareness campaign promoting five Choosing Wisely recommendations. Patel said early data show that participating residents are more comfortable thinking about cost of care and feel better equipped to deliver high-value care. “By being critical, you can really optimize value,” he said.

 

This article originally appeared in print in the February/March 2016 issue of the AAMC Reporter.