Health system executives struggling to improve the value of health care delivery can take encouragement from this: Many of today’s medical students are learning about high-value care as part of their training.
That wasn’t the case when Brandon Combs, M.D., an internist at UC Health in Denver, and his friend Tanner Caverly, M.D., an internist at the VA Ann Arbor (Mich.) Healthcare System, were in medical school.
“We noticed that patients often received well-intended medical care that was probably unnecessary, but there wasn’t a place in our training curriculum to help identify and limit such occurrences,” says Combs, assistant professor at the University of Colorado School of Medicine.
In 2012, they co-founded the Do No Harm project, in which medical students and residents are invited to write a short narrative describing an experience in which medical overuse resulted in — or posed the threat of — harm to a patient. Participants must cite evidence from the medical literature that supports their argument about the specific overuse and evidence about how performance could be improved. The project inspired JAMA Internal Medicine to launch its Teachable Moment series. By publishing many of the Do No Harm case studies, the series allows medical trainees — and all other readers — around the world to learn from the authors’ reflections on low-value care.
Meanwhile, Mayo Clinic School of Medicine and Arizona State University included high-value care as one of six domains in their new Science of Health Care Delivery curriculum that launched in 2015. Other domains include team-based care, population-based care and person-centered care.
Developed with funding from the American Medical Association's Accelerating Change in Medical Education initiative and the Kern Family Foundation, the curriculum seeks to train physicians to deliver care that improves patient outcomes, lowers costs and enhances the patient experience. The concepts of high-value care and the other domains are introduced in classroom presentations and online modules.
“We are trying to get as much of this content as we can presented in the first couple of years so students understand it is foundational to being a doctor,” says Stephanie Starr, M.D., director of Science of Healthcare Delivery Education at Mayo.
In their third year, students will use a “checkbook exercise” in which they review the charges associated with specific patients for whom they cared.
“They can consider: ‘Was there anything that we ordered that we probably didn't need to order? We did that blood test every day. Was that really needed?’” Starr says. “We know there is learning in self-reflection.”
Additionally, through a conversation with a simulated patient who is seeking a low-value test, the students will practice talking with patients about how doing more tests may not help them — and actually can be harmful.
Another domain in the Mayo/ASU curriculum is leadership, an attribute that will be essential to students who are learning about value to translate into clinical practice.
“The biggest challenge is how to enable them to actually be change agents,” she says. “They see the importance of high-value care concepts, but what we have to do as medical educators, practice leaders and health system leaders is to set up the culture that allows change. If that doesn't happen, the curriculum alone isn't enough.”