Communicating value to patients-a high-value care communication skills curriculum.

INTRODUCTION: With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. OBJECTIVE: We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. METHODS: Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. RESULTS: 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). CONCLUSION: There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

Choosing Daily Labs Wisely in the Hospital: A Novel Tool for Assessing Laboratory Testing Appropriateness.

BACKGROUND: The Minnesota Lab Appropriateness (MLAB) criteria were developed for assessing appropriateness of complete blood counts (CBCs) and serum electrolyte panels (SEPs) ordered for adult inpatients. METHODS: Two independent raters used the MLAB criteria to rate appropriateness of labs ordered during 50 hospitalizations through retrospective medical record review. RESULTS: Evaluation of 208 CBCs and 253 SEPs on a 2-category scale (appropriate/inappropriate) resulted in an inappropriate lab rate of 24% and 25% for CBCs and SEPs, respectively. Using a 3-category Likert scale that included an "equivocal" rating to allow for clinical uncertainty, 17% of CBCs and 20% of SEPs were considered inappropriate. Interrater reliability was "substantial" using the dichotomous scale for both CBCs and SEPs. Using the 3-category Likert scale, reliability was "substantial" for CBCs and "moderate" for SEPs. CONCLUSION: The MLAB criteria identified inappropriate labs at a rate consistent with published figures, with good interrater reliability.

Interactive value-based curriculum: a pilot study.

BACKGROUND: Current health care costs are unsustainable, with a large percentage of waste attributed to doctor practices. Medical educators are developing curricula to address value-based care (VBC) in education. There is, however, a paucity of curricula and assessments addressing levels higher than 'knows' at the base of Miller's pyramid of assessment. Our objective was to: (1) teach residents the principles of VBC using active learning strategies; and (2) develop and pilot a tool to assess residents' ability to apply principles of VBC at the higher level of 'knows how' on Miller's pyramid. METHODS: Residents in medicine, medicine-paediatrics and medicine-dermatology participated in a 5-week VBC morning report curriculum using active learning techniques. Early sessions targeted knowledge and later sessions emphasised the application of VBC principles. Medical educators are developing curricula to address value-based care in education RESULTS: Thirty residents attended at least one session and completed both pre- and post-intervention tests, using a newly developed case-based assessment tool featuring a 'waste score' balanced with 'standard of care'. Residents, on average, reduced their waste score from pre-intervention to post-intervention [mean 8.8 (SD 6.3) versus mean 4.7 (SD 4.6), p = 0.001]. For those who reduced their waste score, most maintained or improved their standard of care. DISCUSSION: Our results suggest that residents may be able to decrease health care waste, with the majority maintaining or improving their management of care in a case-based assessment after participation in the curriculum. We are working to further incorporate VBC principles into more morning reports, and to develop further interventions and assessments to evaluate our residents at higher levels on Miller's pyramid of assessment.

Teaching high-value care: a novel morning report.

BACKGROUND: Despite rising health care costs and calls for the incorporation of high-value care (HVC) into medical training, there are few described curricula to address this need. METHODS: We designed a single-group pre/post comparison to evaluate the impact of a 45-minute HVC morning report in one academic internal medicine programme on the trainees' self-reported knowledge of costs for common diagnostic tests, impact on future ordering practices and the educational value of the intervention. Medical trainees completed a diagnostic evaluation for a hypothetical case within the constraints of a budget during the morning report. Trainees completed a pre/post intervention survey regarding knowledge and attitudes towards HVC, and an evaluation of the intervention. The Wilcoxon signed rank test was used to determine differences between the pre/post intervention survey responses. There are few described curricula to address the need for the incorporation of high-value care into medical training RESULTS: Fifty-eight trainees participated in the educational activity: 57 completed the survey and 54 completed the evaluation. Our results indicate a significant increase following the morning report intervention in: the trainees' self-reported understanding of the cost for diagnostic tests (p < 0.001); the likelihood the cost of diagnostic tests would affect their future ordering practices (p < 0.001); and the likelihood that the cost of diagnostic tests would affect their timing of a diagnostic evaluation (p ≤ 0.001). The results also indicated a significant decrease in the likelihood that trainees would order extra diagnostic evaluations following the intervention (p = 0.015), and 96 per cent felt that the session was educationally valuable. DISCUSSION: A morning report incorporating cost of care can significantly increase trainees' perceived understanding of cost and affect self-reported ordering practices in an educationally valuable intervention.

Burnout and Physical Activity in Minnesota Internal Medicine Resident Physicians.

BACKGROUND: Regular physical activity plays an important role in the amelioration of several mental health disorders; however, its relationship with burnout has not yet been clarified. OBJECTIVE: To determine the association between achievement of national physical activity guidelines and burnout in internal medicine resident physicians. METHODS: A Web-based survey of internal medicine resident physicians at the University of Minnesota and Hennepin County Medical Center was conducted from September to October 2012. Survey measures included the Maslach Burnout Inventory-Human Services Survey and the International Physical Activity Questionnaire. RESULTS: Of 149 eligible residents, 76 (51.0%) completed surveys, which were used in the analysis. Burnout prevalence, determined by the Maslach Burnout Inventory, was 53.9% (41 of 76). Prevalence of failure to achieve US Department of Health and Human Services physical activity guidelines was 40.8% (31 of 76), and 78.9% (60 of 76) of residents reported that their level of physical activity has decreased since they began medical training. Residents who were able to meet physical activity guidelines were less likely to be burned out than their fellow residents (OR, 0.38, 95% CI 0.147-0.99). CONCLUSIONS: Among internal medicine resident physicians, achievement of national physical activity guidelines appears to be inversely associated with burnout. Given the high national prevalence of burnout and inactivity, additional investigation of this relationship appears warranted.