Tackling the Minimizers Hiding Behind High-Value Care

With the escalating need for academic health centers to control costs, high-value care initiatives targeted at residents have exploded. Recent estimates suggest that more than two-thirds of internal medicine residency programs have high-value care curricula.¹ This growth has been catalyzed, in part, by compelling evidence suggesting that where the residents undergo training is strongly associated with their future utilization.² Although we encourage, support, and participate in high-value care education, as hospitalists, there are potential consequences of the high-value care movement in medical training.

Minimizers – physicians who underestimate the signs and symptoms of a patient, hastily concluding that they have the most benign condition possible – have always existed within residency training. The ethos of “doing nothing” has been around since at least the days of the widely read medical satire House of God.³ However, the increasing focus on high-value care creates a socially acceptable banner for minimizers to hide behind when defending inappropriately doing less. For an inpatient with unexplained localized abdominal pain not responding to conservative therapy, a minimizing resident may report to the attending, “They’re fine. I am trying to practice high-value care and avoid getting a CT scan.”

In their 2011 book, Your Medical Mind, Groopman and Hartzband described how people naturally fall on a scale between medical maximizing and minimizing and how this influences their approach toward healthcare.⁴ Researchers have expanded this construct to create a “Maximizer-Minimizer Scale,” which has been used for studying patients and how these traits affect the degree of medical care they receive.⁵ Similar approaches could be used for identifying physicians and trainees at risk of too much minimizer behavior. Although the vast majority of trainees are not minimizers, and overuse continues to be the bigger problem in the majority of academic settings, it is important to understand how the high-value care movement could facilitate minimalist behavior in some residents. Although this article focuses on the educational system, the potential for minimization exists at all levels of clinical practice, including faculty and practicing physicians. Tackling this problem requires understanding the factors that promote the creation of minimizers, how patients and trainees are affected, and the solutions for preventing the spread of minimizers.

Several factors may predispose a resident physician to become a minimizer. For example, resident burnout and overwhelming caseloads can contribute to the desire to decrease work by any means necessary. There are several ways a minimizer can accomplish this goal on inpatient rounds. First, a minimizer may present an important or acute problem as an “outpatient issue” that does not require inpatient workup. Second, minimizers may avoid requesting necessary consults, particularly those associated with intensive workups such as neurology, infectious disease, and rheumatology. Minimizers would claim that this is because of a concern of an unnecessary “costly workup,” when in reality they fear discovery of new problems, more tests to follow-up, and a potentially prolonged length of stay. Ironically, an institutional focus on hospital throughput can reinforce minimizers since the attending physicians or the hospital administrators may applaud them for avoiding “extra nights” in the hospital.