Doctors as Resource Stewards? Translating High-Value, Cost-Conscious Care to the Consulting Room.

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system-paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide 'high-value, cost-conscious care' (HVCCC), which proponents believe is the future of sustainable medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors' professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients-redefining the currency of value from monetary costs to a patient's quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation.

Toward High-Value, Cost-Conscious Care - Supporting Future Doctors to Adopt a Role as Stewards of a Sustainable Healthcare System.

PHENOMENON: In order to tackle the persistent rise of healthcare costs, physicians as "stewards of scarce resources" could be effective change agents, extending cost containment efforts from national policy to the micro level. Current programs focus on educating future doctors to deliver "high-value, cost-conscious care" (HVCCC). Although the importance of HVCCC education is increasingly recognized, there is a lag in implementation. Whereas recent efforts generated effective interventions that promote HVCCC in a local context, gaps persist in the examination of system factors that underlie broader successful and lasting implementation in educational and healthcare practices. APPROACH: We conducted a realist evaluation of a program focused on embedding HVCCC in postgraduate education by encouraging and supporting residents to set up "HVCCC projects" to promote HVCCC delivery. We interviewed 39 medical residents and 10 attending physicians involved in such HVCCC projects to examine HVCCC implementation in different educational and healthcare contexts. We held six reflection sessions attended by the program commissioners and educationalists to validate and enrich the findings. FINDINGS: A realist evaluation was used to unravel the facilitators and barriers that underlie the implementation of HVCCC in a variety of healthcare practices. Whereas research activities regularly stop after the identification of facilitators and barriers, we used these insights to formulate four high-value, cost-conscious care carriers: (1) continue to promote HVCCC awareness, (2) create an institutional structure that fosters HVCCC, (3) continue the focus on projects for embedding HVCCC in practice, (4) generate evidence. The carriers support residents, attendings and others involved in educating physicians in training to develop and implement innovative HVCCC projects. INSIGHTS: Strategies to promote physician stewardship go beyond the formal curriculum and require a transformation in the informal educational system from one that almost exclusively focuses on medical discussions to one that also considers value and cost as part of medical decision-making. The HVCCC carriers propose a set of strategies and system adaptations that could aid the transformation toward a HVCCC supporting context.

Shared decision-making in undergraduate nursing and medical education: An explorative dual-method study.

OBJECTIVE: This study explores how shared decision-making (SDM) is integrated in undergraduate nursing and medical education. METHODS: A dual-method design was applied. The integration of SDM in medicine and nursing education programs (i.e. SDM on paper) was explored through document analyses; the integration of SDM in curricula (i.e. SDM in class) through interviews with teachers and curriculum coordinators (N = 19). RESULTS: A majority of the education programs featured SDM, mostly non-explicit. In curricula SDM was generally implicitly featured in compulsory courses across all study years. SDM was often integrated into preexisting theories and models and taught through various methods and materials. Generally, teachers and supervisors were not trained in SDM themselves. They assessed students' competence in SDM in a summative manner. CONCLUSION: Overall, SDM was featured in undergraduate nursing and medical education, however, very implicitly.