Tackling the Minimizers Hiding Behind High-Value Care

In addition to high workloads, inadequate clinical expertise favors the creation of minimizers. Although resident physicians may be aware that the probability of a rare disease is low, they may not recognize when ruling it out is appropriate. Thus, they could dismiss subtle cues or patterns that point to the need for further workup. Although attending physicians serve as a safety net, it could take time for them to recognize a resident minimizer who may be presenting biased information that influences their clinical decisions. Moreover, attending physicians may avoid further probing so that they are not perceived as promoting overuse and waste.

There are several dangers posed by minimizers, but the most concerning is the impact on patients. Missed diagnoses are a common source of patient maltreatment and contribute to avoidable deaths.⁶ Patients treated by minimizers may continue to experience their acute problem or have to be readmitted because of inadequate treatment. These patients may also lose faith or their trust in the medical system because of inattention to their problems. In fact, minimizing behaviors could have the greatest negative impact on the most vulnerable patients, who often cannot advocate for themselves or who may face conscious and unconscious biases, such as assumptions that they are “pain medication-seeking.”

In addition to harming patients, minimizers can jeopardize learning opportunities. A minimizer resident squanders the chance to recognize and contribute toward caring for a patient with a rare disease, diminishing their overall clinical development. Other trainees lose the opportunity to learn due to consultations or procedures never obtained. Lastly, as inappropriate attitudes and practices of minimizers spread through the hidden curriculum, particularly to medical students beginning their training, the overall clinical learning environment suffers.

There are specific techniques that academic hospitalists and teaching attending physicians can use to help curb the creation of minimizers and promote a clinical learning environment that counters these behaviors. First, instead of focusing on financial costs, it is important for educators to teach the true concept of healthcare value and the primary importance of improving patient outcomes. Embedding appropriateness criteria, such as those from the American College of Radiology, into daily workflows can enable residents to consider not just the cost of imaging but rather the appropriateness given a specific indication.⁷ Training programs can provide residents with a closed-loop feedback on patient outcomes so that they can recognize whether a diagnosis was missed or a necessary test was not ordered. Additionally, it is critical for residents to understand that improving healthcare value requires taking a big picture view of costs, particularly from the perspective of patients.⁸ A patient readmitted after receiving a minimalist workup is more costly to both the patient and the healthcare system.

Second, it is important for the hospitalist faculty to emphasize when a patient has failed a conservative approach and a more specialized, and sometimes intensive, workup or management strategy is appropriate. The classic example is a patient transferred from a community hospital to a tertiary center for further evaluation. Such patients are outside the scope of well-established guidelines. It is precisely these patients that Choosing Wisely or “Less is More” recommendations often do not apply. In contrast, transfer patients often do not end up receiving the specialty procedures that they were originally referred for⁹; it is important that all remain vigilant and committed to high-value care to avoid overuse in these situations.

Exposing residents to cognitive biases is equally important. For example, anchoring can lead to early closure, an easy path for a minimizer to follow. Given the recent focus on the harms related to diagnostic errors, more training in these biases can help promote better patient outcomes.¹⁰

Lastly, it is critical that hospitalists emphasize the importance of prioritizing a patient’s overall health to learners. Although it is tempting for trainees to focus only on acute episodes of a hospital stay, a holistic approach to patients and their quality of life can avoid the minimizer trap. The recent proposal to use home-to-home days in lieu of the routine length of hospital stay is a wonderful example of “measuring what matters to patients” and removing incentives for inappropriately shifting care to other clinicians or venues.¹¹ Likewise, alternative payment models for emphasizing patient outcomes over time can create systems that reinforce holistic views of patient health.