Assessing Student Attitudes Regarding Cost-Consciousness in Medical Education.

This article was migrated. The article was marked as recommended. Purpose: The purpose of this study was to compare attitudes regarding cost-consciousness between student populations at two medical schools in the United States and Canada. Method: We conducted a cross-sectional survey of students at Harvard Medical School and University of Toronto. We performed chi-square analyses comparing responses from the two institutions. Results: Response rates were 48% (n=162) and 45% (n=228) at Harvard and the University of Toronto, respectively. At both institutions, >96% of students agreed clinicians at all stages of training should be familiar with cost-conscious decision-making, 80% agreed physicians are responsible for discussing healthcare costs with patients, and over 80% felt they had too little education on the topic in medical school. Students differed in opinions about the extent to which patients should inquire about costs, with students at Harvard more likely to endorse this opinion compared with those from Toronto (51% vs 28%, respectively), and differed over whether cost-consciousness led to rationing of healthcare (Harvard 30% vs Toronto 51%). Fewer than 10% of all students expressed concerns that incorporating costs into care was unethical. Overall, 85% of students from both countries would like more formal teaching on this topic. Discussion: Students from both schools strongly endorsed a need to learn more about cost-conscious decision-making. Findings suggest students in both systems can benefit from learning similar core concepts related to high-value, cost-conscious care, and teaching in this topic can be customized to reflect specific differences in expectations and practices in the two healthcare systems.

Achieving Procedural Competence during Nephrology Fellowship Training: Current Requirements and Educational Research.

Concerns have previously been raised as to whether training programs are ensuring that nephrology fellows achieve competence in the procedural skills required for independent practice. We sought to review the current requirements for procedural training as well as educational research pertaining to achieving competence in the core nephrology procedures of nontunneled (temporary) hemodialysis catheter insertion and percutaneous kidney biopsy. At this time, there is no universal approach to procedural training and assessment during nephrology fellowship. Nonetheless, simulation-based mastery learning programs have been shown to be effective in improving fellows' skills in nontunneled (temporary) hemodialysis catheter insertion and should be provided by all nephrology training programs. For percutaneous kidney biopsy, the development and evaluation of inexpensive simulators are a promising starting point for future study. Current practice with respect to procedural training during nephrology fellowship remains imperfect; however, the ongoing shift toward competency-based evaluation provides opportunities to refocus on improvement.

Performance of Temporary Hemodialysis Catheter Insertion by Nephrology Fellows and Attending Nephrologists.

BACKGROUND AND OBJECTIVES: Concerns have been raised about nephrology fellows' skills in inserting temporary hemodialysis catheters. Less is known about temporary hemodialysis catheter insertion skills of attending nephrologists supervising these procedures. The aim of this study was to compare baseline temporary hemodialysis catheter insertion skills of attending nephrologists with the skills of nephrology fellows before and after a simulation-based mastery learning (SBML) intervention. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This pre- post-intervention study with a pretest-only comparison group was conducted at the University of Toronto in September of 2014. Participants were nephrology fellows and attending nephrologists from three university-affiliated academic hospitals who underwent baseline assessment of internal jugular temporary hemodialysis catheter insertion skills using a central venous catheter simulator. Fellows subsequently completed an SBML intervention, including deliberate practice with the central venous catheter simulator. Fellows were expected to meet or exceed a minimum passing score at post-test. Fellows who did not meet the minimum passing score completed additional deliberate practice. Attending nephrologist and fellow baseline performance on the temporary hemodialysis catheter skills assessment was compared. Fellows' pre- and post-test temporary hemodialysis catheter insertion performance was compared to assess the effectiveness of SBML. The skills assessment was scored using a previously published 28-item checklist. The minimum passing score was set at 79% of checklist items correct. RESULTS: In total, 19 attending nephrologists and 20 nephrology fellows participated in the study. Mean attending nephrologist checklist scores (46.1%; SD=29.5%) were similar to baseline scores of fellows (41.1% items correct; SD=21.4%; P=0.55). Only two of 19 attending nephrologists (11%) met the minimum passing score at baseline. After SBML, fellows' mean post-test score improved to 91.3% (SD=6.9%; P<0.001). Median time between pre- and post-test was 24 hours. CONCLUSIONS: Attending nephrologists' baseline temporary hemodialysis catheter insertion skills were highly variable and similar to nephrology fellows' skills, with only a small minority able to competently insert a temporary hemodialysis catheter. SBML was extremely effective for training fellows and should be considered for attending nephrologists who supervise temporary hemodialysis catheter insertions.