Use of simulation to assess incoming interns’ recognition of opportunities to choose wisely
BACKGROUND
Despite increasing healthcare costs, training on cost-consciousness is lacking in graduate medical education (GME). Medical centers must consider how best to incorporate value-based training into their GME curricula.
OBJECTIVE
To incorporate low-value principles into an existing GME simulation exercise and assess incoming interns’ recognition of low-value care.
METHODS
Choosing Wisely™ lists were reviewed to identify 4 low-value hazards to be embedded into a simulated hospital room in addition to the 8 patient safety hazards used previously. Interns were given 10 minutes to independently review a mock chart and list all hazards they identified in the simulation. Interns completed a short survey on their prior training in medical school and a follow-up survey one month into internship. T tests used to compare identification of low-value vs safety hazards and to associate performance with prior training.
RESULTS
The mean percentage of hazards correctly identified was 50.4% (standard deviation [SD] 11.8%). Interns identified significantly fewer low-value hazards (mean 19.2%, SD 18.6%) than safety hazards (mean 66.0%, SD 16.0%; P < .001). For example, while 96% of interns identified the hand hygiene hazard, only 6% identified the unnecessary blood transfusion and none identified the unnecessary stress ulcer prophylaxis. Interns who self-reported as confident in their ability to identify hazards were not any more likely to correctly identify hazards than those who were not confident.
CONCLUSIONS
The “Room of Horrors” simulation revealed poor awareness of low-value care among interns. The simulation highlights a promising model for the prioritization and inclusion of value-based experiential training in GME. Journal of Hospital Medicine 2017;12:493-497. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
In recent years, the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely™ campaign has advanced the dialogue on cost-consciousness by identifying potential examples of overuse in clinical practice.1 Eliminating low-value care can decrease costs, improve quality, and potentially decrease patient harm.2 In fact, there is growing consensus among health leaders and educators on the need for a physician workforce that is conscious of high-value care.3,4 The Institute of Medicine has issued a call-to-action for graduate medical education (GME) to emphasize value-based care,5 and the Accreditation Council for Graduate Medical Education has outlined expectations that residents receive formal and experiential training on overuse as a part of its Clinical Learning Environment Review.6
However, recent reports highlight a lack of emphasis on value-based care in medical education.7 For example, few residency program directors believe that residents are prepared to incorporate value and cost into their medical decisions.8 In 2012, only 15% of medicine residencies reported having formal curricula addressing value, although many were developing one.8 Of the curricula reported, most were didactic in nature and did not include an assessment component.8
Experiential learning through simulation is one promising method to teach clinicians-in-training to practice value-based care. Simulation-based training promotes situational awareness (defined as being cognizant of one’s working environment), a concept that is crucial for recognizing both low-value and unsafe care.9,10 Simulated training exercises are often included in GME orientation “boot-camps,” which have typically addressed safety.11 The incorporation of value into existing GME boot-camp exercises could provide a promising model for the addition of value-based training to GME.
At the University of Chicago, we had successfully implemented the “Room of Horrors,” a simulation for entering interns to promote the detection of patient safety hazards.11 Here, we describe a modification to this simulation to embed low-value hazards in addition to traditional patient safety hazards. The aim of this study is to assess the entering interns’ recognition of low-value care and their ability to recognize unsafe care in a simulation designed to promote situational awareness.
METHODS
Setting and Participants
The simulation was conducted during GME orientation at a large, urban academic medical institution. One hundred and twenty-five entering postgraduate year one (PGY1) interns participated in the simulation, which was a required component of a multiday orientation “boot-camp” experience. All eligible interns participated in the simulation, representing 13 specialty programs and 60 medical schools. Interns entering into pathology were excluded because of infrequent patient contact. Participating interns were divided into 7 specialty groups for analysis in order to preserve the anonymity of interns in smaller residency programs (surgical subspecialties combined with general surgery, medicine-pediatrics grouped with internal medicine). The University of Chicago Institutional Review Board deemed this study exempt from review.
