Approximately $700B of annual healthcare spending is wasted, with physicians directly influencing 87% of this expenditure. Medical training has emphasized quality improvement but few programs are addressing the ACGME requirement that physicians–in–training now “incorporate considerations of cost awareness” into practice.
To develop an inpatient curriculum to promote cost awareness, highlight current clinical guidelines, improve physician attitudes towards cost control, and cultivate more cost–effective physician ordering behaviors.
We first reviewed the literature on strategies to address discrepancies between physicians’ desired and actual knowledge of health care costs. The most valued educational strategy for residents has been case–based conferences. We selected a group of 12 “core topics” of commonly encountered internal medicine clinical scenarios with frequent practice and resource–utilization variability, including syncope, chest pain, low back pain and pulmonary embolism. We created a longitudinal curriculum involving all PGY1 residents, as well as a monthly case–based conference for on–service medical students, residents, and attendings. Each month five PGY1 residents participated in a 1–hour introductory cost awareness session during a quality improvement rotation. We provided them with Background reading and an anonymous, itemized hospital statement for one of the “core” diagnoses. The learners were divided into two groups: one focusing on reviewing evidence–based guidelines and the other evaluating common practices and relevant charges. We reconvened these groups for a facilitated session to present and integrate their findings. This portion of the curriculum involved two one1–hour sessions and less than five 5 hours of independent work for the PGY1 residents. We then prepared a monthly case–based noon conference from these collective lessons. During this conference, we reviewed the specific case and underscored appropriate evidence–based, cost–effective care. Our early experience with this curriculum, during the 2011–2012 academic year, has been highly positive. We received 116 evaluations from six conferences involving medical students (n = 38), residents (n = 65) and attendings (n = 13). Respondents reported that the conferences were highly relevant to their clinical practices (mean of 4.47 [pm] 0.65 on a 5–point Likert scale) and that they were likely to change their ordering behaviors based on the conferences (mean of 4.19 [pm] 0.72).
A resident–led educational innovation involving a monthly PGY1 curriculum, with active preparation of a facilitated, case–based conference emphasizing evidence–based and cost–effective medical practices, can be well–received, highly relevant, and likely to change ordering behaviors of a diverse internal medicine audience. The time and resources required to implement this curriculum are relatively minimal, making this paradigm sustainable and adaptable to other institutions.