Background: Repetitive morning laboratory orders are a well-known contributor to healthcare cost. Initial data collected in a related project on high-value care showed that 35% of our Internal Medicine residents identified “fear of attendings” as a reason to order morning labs on the inpatient Medicine service. This observation led us to design a project on the attending physician as a barrier to high-value care—with a focus on their knowledge of mindful care as well as their relationship with the resident team.
Purpose: Data was collected via anonymous pre/post survey (designed by the study team) that included yes/no, multiple choice and Likert scale questions. Participants included Internal Medicine residents and inpatient attending physicians. Multiple interventions occurred over a 16-week period. Interventions included a presentation at the monthly hospitalist meeting (update on resident lab-ordering practices and data on resident perceptions of attendings as barrier to mindful care). Electronic requests asked attendings to voluntarily submit a message of support for the project; messages were shared with residents via email and team-room posting throughout the project. Attendings were asked to take a picture with the project logo; these photos were included in noon report presentations. An attending project champion was identified to email attendings on service with reminders to discuss lab ordering with their teams.
Description: Pre-intervention data showed that 25% of residents and 78% of attendings report attending-resident discussion of mindful lab ordering “more than half the time”. 60% of residents reported discussing labs before ordering with their team “more than half the time” while only 23% report discussing labs before ordering with their attending. 72% of attendings report self-initiating the majority of lab discussions.
Conclusions: Our initial data shows a discrepancy between attending and resident perception of the attending-resident discussion regarding ordering labs. Markedly fewer residents report attending-resident lab discussions when compared with attendings’ reported conversations. While post-intervention data is pending, we hypothesize that this difference may be related to the directness of the discussion, similar to the phenomenon when residents do not realize feedback is provided unless expressly told. Additionally, as residents had received approximately one year of education on mindful ordering practices prior to this study, it is possible that the residents and attendings have variable expectations on what qualifies as a discussion. Finally, residents report discussing labs with their “team” more often than with the attending. It is unclear if this is due to the residents’ discomfort with the attending or the attending’s availability. We are hopeful that our post-intervention data will support a cultural shift toward improved resident-attending interactions and more mindful lab ordering practices.