Background: High-value care (HVC) education is crucial for developing cost- and quality-conscious physicians. This study assesses the impact of a first-year HVC course on experiences in longitudinal ambulatory clerkship (LAC), examining changes with time and gender.
Methods: This prospective study lasting from 2021-2024 included first and second-year medical students (n=265) in LAC. Students were divided into groups based on enrollment (n=113) or no enrollment (n=152) in a first-year HVC course. Surveys assessed perceived HVC culture (composite score), comfort in discussing HVC, perceived receptiveness, excess testing, and barriers to HVC. Chi-square tests and t-tests compared outcomes between groups by course enrollment. Linear and logistic regressions analyzed the effects of course participation while controlling for gender. Linear mixed-effects models evaluated year-over-year changes.
Results: In year 1, average HVC scores based on reported discussions on cost and consideration of HVC were similar between those who did or did not take the course (2.81 vs 2.93, p=0.19). However, while taking the course in year 1, course participants reported more barriers related to fear of poor evaluations (18% vs 9%, p=0.04) and lack of knowledge (65% vs 47%, p=0.008) compared to those who did not take the course. By year 2, these differences diminished. In year 2, a higher proportion of course participants reported recognizing the ordering of excess tests (40% vs 21%, p=0.01). After regression controlling for gender, students who took the HVC course had higher odds in both years 1 (OR: 2.35, 95% CI: 1.12 – 5.12, p-0.026) and 2 (OR: 2.98, 95% CI: 1.05 – 9.22, p-0.040) to recognize excess testing. Linear mixed-effects models showed significant improvements in comfort discussing HVC in year 2 compared to year 1 (β=0.48, SE 0.10, p< 0.001) but persistent gender differences with females reporting decreased comfort (β=-0.26, SE 0.13, p< 0.05) and increased feeling not knowledgeable enough to discuss HVC (β=0.10, SE 0.048, p< 0.05). Course participation was associated with higher average HVC scores (β=0.16, SE 0.07, p< 0.05) and greater recognition of excess testing (β=0.17, SE 0.05, p< 0.01) over time. Between years 1 and 2, lack of knowledge decreased overall (β=-0.16, SE 0.043, p< 0.001) regardless of course enrollment and gender.
Conclusions: While early HVC education increased awareness of knowledge gaps and improved aspects of HVC perception over time, it did not consistently improve HVC practices over two years. Gender differences in HVC perceptions persisted, highlighting the need for further targeted evaluation of gender-associated barriers. The increased reporting of excess testing among course participants suggests a heightened awareness of HVC principles but indicates challenges in practical application. Future research should address gender-specific barriers to HVC and bridge the gap between HVC knowledge and practice in clinical settings.