High-value care education can learn from the evidence-based medicine movement: moving beyond competencies and curricula to culture

• Published in: BMJ evidence-based medicine Vol. 29; no. 3; p. 147
• Main Authors: Moriates, Christopher, Silverstein, William K, Bandeira de Mello, Renato, Stammen, Lorette, Wong, Brian M
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01.06.2024
• Subjects: Accreditation; Behavior; Clinical Competence - standards; Core curriculum; Cost estimates; Curriculum; Decision making; Education, Medical - methods; Evidence-Based Medicine - education; Evidence-based practice; Health services utilization; Humans; Knowledge; Leadership; Medical education; Medical students; Medicine; Patients; Physicians; Quality improvement; Surgeons; Systematic review; Teaching; Canada; United States > US; Evidence-Based Practice; Quality of Health Care
• ISSN: 2515-446X; 2515-4478
• DOI: 10.1136/bmjebm-2023-112270

Professional knowledge The health service and healthcare systems in the four countries Understand how resources are managed, being aware of competing demands and the importance of avoiding waste Royal Australasian College of Physicians Professional Practice Framework (Australia and New Zealand) Judgement and decision-making Diagnostic reasoning Apply judicious and cost-effective use of health resources to their practice Accreditation Council for Graduate Medical Education Competencies (USA) Systems-based practice Incorporating considerations of value, cost awareness, delivery and payment, and risk benefit analysis in patient and/or population-based care as appropriate Association of American Medical Colleges Quality Improvement and Patient Safety Competencies Quality improvement High-value care (entering residency) Recognises uncoordinated, wasteful, and unnecessary healthcare delivery Articulates the ethical case for stewarding resources and cost conscious care, including the potential impact of clinical decisions on whether the patient can afford the cost Recognises wide variations exist in healthcare utilisation and care delivery patterns across individuals, health systems, and regions that seem to be independent of patients’ needs Quality improvement High-value care (entering practice) Manages the interrelated components of the complex healthcare systems for efficient and effective patient care Considers cost when practising medicine Considers cost when practising medicine Minimises unnecessary deviation of practice from recommended guidelines or local standards Quality improvement High-value care (experienced faculty physician) Advocates or leads change to enhance systems for high-value, efficient and effective patient care Incorporates cost-awareness principles into delivery of complex clinical care Contributes to practice and system level changes to reduce unnecessary and unwarranted variation Over the past decade, HVC education has progressively been introduced into medical training in many countries across the world.11 12 A 2015 systematic review assessing which interventions effectively promote HVC to practising physicians, resident physicians and medical students included 14 randomised clinical trials; 12 addressed knowledge transmission (major themes included cost, evidence and patient preferences); 7 reflective practice (such as audit/feedback and interactive discussions) and 1 supportive environment (some of the trials included more than one intervention category). Ten (71%) of these studies concluded that the intervention was effective at either changing behaviour (eg, showing a significant decrease in a target area of overuse) or increasing knowledge (eg, more accurate cost estimates for common interventions).11 Despite varied examples, the systematic review revealed many limitations of current approaches including that most curricula focused on a single clinical service or site rather than engaging a broader group of clinicians to achieve scale, emphasised cost-containment rather than care appropriateness, employed suboptimal study designs, and did not evaluate outcomes reflecting medical student or resident physicians’ ability to deliver HVC following training.6 However, HVC education has advanced in the 7 years since this systematic review was published. [...]in the USA, multiple medical schools and residency training programmes have adopted freely available online programmes and tools related to HVC, which have shown improvements in specific HVC knowledge, attitudes and self-reported HVC practices.13 The Royal College of Physicians and Surgeons in Canada created a Resource Stewardship Curriculum Toolkit Series as a free downloadable digital resource for clinician educators.14 In Germany, a video-based training programme to teach medical students to choose appropriate diagnostic tests, arrive at correct diagnoses and identify advisable therapies was shown to be more effective than text-based training.15 EBM leaders viewed inclusion in assessment and accreditation standards as an important component to more systematic adoption.3 Assessment is an emerging focus of HVC education efforts, with recent progress developing HVC-related content within traditional assessment methods such as multiple-choice question examinations (eg, the US Internal Medicine In-Training Examination includes a HVC subscore), and the development of objective structured clinical exam (OSCE) scenarios that assess trainees’ abilities to communicate appropriate HVC recommendations (eg, avoiding unnecessary imaging for a patient with routine low back pain). [Professor Carl Heneghan]3 Although effective knowledge transition of key HVC concepts through formal medical education is needed, the informal, or ‘hidden’, curriculum within training environments has long-lasting influences on practice patterns.17 Several studies demonstrate that residents who train in environments with lower healthcare utilisation are more likely to recognise when conservative approaches are appropriate and vice-versa.18–22 This ‘imprinting’ effect, whereby the intensity of resource utilisation impacts future individual practice patterns, can be seen up to at least 15 years after graduation, with those from high-intensity training environments still using more resources even when the graduate moves and practices in a lower clinical care spending setting.21 Therefore, as in the EBM movement, a lynchpin to successful HVC education is faculty role-modelling of HVC behaviours.22 23 One example of an evidence-based approach to effective role modelling of HVC practices comes from a study in the Netherlands.23 In this study, semistructured interviews of attending physicians who supervise residents in the workplace identified approaches that helped create supportive environments for HVC training, including explicitly making HVC a shared goal for attending physicians and residents.