Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians
ABSTRACT There is general agreement that the U.S. economy cannot sustain the staggering economic burden imposed by the current and projected costs of health care. Whereas governmental approaches are focused primarily on decreasing spending for medical care, it is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of health care costs. At present, the 6 general competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) that drive residency training place relatively little emphasis on residents' understanding of the need for stewardship of resources or for practicing in a cost-conscious fashion. Given the importance in today's health care system, the author proposes that cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new, seventh general competency. This will hopefully provide the necessary impetus to change the culture of the training environment and the practice patterns of both residents and their supervising faculty.
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ABSTRACT: Background: Stewardship is an important aspect of medical care to which little formal attention is paid during training. Purpose: The goal is to evaluate stewardship practices of internal medicine residents and the relationship of resident refusal to provide requested nonindicated care with levels of confidence and bother. Methods: Cross-sectional survey of residents in one training program, containing four hypothetical clinical scenarios asking residents whether they would provide nonindicated tests and treatments, and to report confidence in the decision and bother. Results: Sixty-seven of 105 residents completed the survey. Most residents prescribed a requested brand-name expensive medication when a generic was available and hospitalized a patient with no expected clinical benefit, but few were willing to repeat imaging for quicker availability or perform an unnecessary diagnostic evaluation. Residents ordering nonindicated tests and treatments reported lower confidence in their decision and more bother. PGY level was not associated with clinical decision or bother. Conclusions: Internal medicine residents, at least on hypothetical scenarios, demonstrate inconsistent stewardship practices. Findings support room for improvement in confidence when faced with requests for nonindicated care and suggest the need for greater curricular emphasis on stewardship.Teaching and Learning in Medicine 04/2013; 25(2):141-7. DOI:10.1080/10401334.2013.770740 · 1.12 Impact Factor
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ABSTRACT: The dialogue at the interface of education and clinical practice highlights areas of critical importance to the development of new approaches for educating anesthesiologists. The purpose of this article is to examine the literature on education and acquisition of competence in three areas relevant to the interface of learning and clinical practice, with the aim to suggest a research agenda that adds to the evidence on preparing physicians for independent practice. The three areas are: 1) transitions across the continuum of education; 2) the effect of reductions in hours of clinical training on competence; and 3) efforts to incorporate the competencies and CanMEDS roles into teaching and evaluation. Fifty-six articles relevant to one or more of the themes were identified in the review, including 21 studies of transitions (in, during, and after residency education), 19 studies on the effects of duty hour limits on residents' acquisition of competence, and 16 articles that assessed competency-based teaching and assessment in anesthesiology. Overall, the findings suggested a relative paucity of scientific evidence and a need for research and the development of new scientific theory. Studies generally treated one of the themes in isolation, while in actuality they interact to produce optimal as well as suboptimal learning situations, while medical education research often is limited by small samples, brief follow-up, and threats to validity. This suggests a "research gap" where editorials and commentaries have moved ahead of an evidence base for education. Promising areas for research include preparation for care deemed important by society, work to apply knowledge about the development of expertise in other disciplines to medicine, and ways to embed the competencies in teaching and evaluation more effectively. Closing the research gap in medical education will require clear direction for future work. The starting point, at an institution or nationally, is dialogue within the specialty to achieve consensus on some of the most pressing questions.Canadian Anaesthetists? Society Journal 12/2011; 59(2):203-12. DOI:10.1007/s12630-011-9639-7 · 2.50 Impact Factor
- Annals of internal medicine 12/2011; 155(12):859-60; author reply 860. DOI:10.1059/0003-4819-155-12-201112200-00018 · 16.10 Impact Factor