0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter | Less Is More

Implementing a Graduate Medical Education Campaign to Reduce or Eliminate Potentially Wasteful Tests or Procedures FREE

Julia A. McMillan, MD1; Roy C. Ziegelstein, MD, MACP2
[+] Author Affiliations
1Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Department of Education, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Intern Med. 2014;174(10):1693. doi:10.1001/jamainternmed.2014.3472.
Text Size: A A A
Published online

The important role of training program directors to educate residents and fellows about the value of cost-conscious diagnostic and management strategies is clear.1 Indeed, a suggestion has been made that cost-conscious care should be added as a seventh general competency by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.2 Recently, Patel et al3 reported the results from a survey by the Association of Program Directors in Internal Medicine in which fewer than 1 of every 6 residency programs had a formal curriculum in cost-conscious care. The following report details our experience implementing an institution-wide campaign related to cost-conscious care at Johns Hopkins University School of Medicine.

METHODS

In late September 2013, we sent an e-mail to the directors of the 90 residency and fellowship programs sponsored by Johns Hopkins University School of Medicine and to the chair of each clinical department. The e-mail emphasized the importance of teaching residents and fellows cost-conscious care and stewardship of resources. It described Choosing Wisely4 and provided a link to the lists of tests and procedures that medical societies have suggested should be considered carefully because of their potential for overuse and possible harm. The e-mail requested that in the next 5 weeks, each residency and fellowship program “identify 1 commonly used unnecessary or wasteful medical test or procedure” in their specialty area and begin to work with trainees to develop and implement an intervention to eliminate it.

RESULTS

After 5 weeks, only 22 of the 90 program directors (24%) identified a test or a procedure and an intervention. In some cases the planned intervention was simply to provide education to residents and faculty members about the lack of evidence for a frequently ordered test or procedure, whereas in other cases a more robust intervention and assessment were proposed. A reminder was sent to program directors after 5 weeks, increasing the number of responses to 29 (32%). After receiving the responses, a discussion at the monthly Graduate Medical Education Committee meeting followed in which medical educators’ responsibility to teach residents and fellows the value of cost-conscious medicine was emphasized. Articles about Choosing Wisely and the importance of high-value, cost-conscious medical care were distributed to program directors. Given the evidence that transparent sharing of performance data may help change physician behavior,5 the list of 29 potentially wasteful medical tests and procedures and interventions to reduce or to eliminate them was shared with program directors who had not responded. These efforts resulted in only 1 additional submission.

Program directors listed several barriers to responding to this charge, including (1) being too busy with other responsibilities; (2) feeling they needed additional technological support to implement interventions and assess outcomes; (3) having no control over the use of tests or procedures in their specialty that were requested by other departments; (4) feeling that this intervention would divert attention from ongoing quality improvement activities in their program; and (5) finding it difficult to develop consensus among faculty members about which test or procedure should be reduced or eliminated.

DISCUSSION

Our experience suggests that efforts to implement cost-conscious care education and practice interventions in graduate medical education by a top-down approach are not likely to result in widespread changes, even with multimodal communication and transparent sharing of performance data and the relatively modest goal of identifying just a single test or procedure to reduce or to eliminate. Given the need for program directors to embrace and lead educational interventions, additional efforts to overcome the perceived or real barriers to implementing change must be addressed more specifically and explicitly.

ARTICLE INFORMATION

Corresponding Author: Julia A. McMillan, MD, Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans St, 8530 Bloomberg, Baltimore, MD 21287 (jmcmill@jhmi.edu).

Published Online: August 18, 2014. doi:10.1001/jamainternmed.2014.3472.

Author Contributions: Drs McMillan and Ziegelstein had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Study supervision: Ziegelstein.

Conflict of Interest Disclosures: None reported.

REFERENCES

Cooke  M.  Cost consciousness in patient care: what is medical education’s responsibility? N Engl J Med. 2010;362(14):1253-1255.
PubMed   |  Link to Article
Weinberger  SE.  Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386-388.
PubMed   |  Link to Article
Patel  MS, Reed  DA, Loertscher  L, McDonald  FS, Arora  VM.  Teaching residents to provide cost-conscious care: a national survey of residency program directors. JAMA Intern Med. 2014;174(3):470-472.
PubMed   |  Link to Article
ABIM Foundation. Choosing Wisely.http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx. Accessed March 31, 2014.
Margolis  PA, DeWalt  DA, Simon  JE,  et al.  Designing a large-scale multilevel improvement initiative: the improving performance in practice program. J Contin Educ Health Prof. 2010;30(3):187-196.
PubMed   |  Link to Article

Figures

Tables

References

Cooke  M.  Cost consciousness in patient care: what is medical education’s responsibility? N Engl J Med. 2010;362(14):1253-1255.
PubMed   |  Link to Article
Weinberger  SE.  Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386-388.
PubMed   |  Link to Article
Patel  MS, Reed  DA, Loertscher  L, McDonald  FS, Arora  VM.  Teaching residents to provide cost-conscious care: a national survey of residency program directors. JAMA Intern Med. 2014;174(3):470-472.
PubMed   |  Link to Article
ABIM Foundation. Choosing Wisely.http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx. Accessed March 31, 2014.
Margolis  PA, DeWalt  DA, Simon  JE,  et al.  Designing a large-scale multilevel improvement initiative: the improving performance in practice program. J Contin Educ Health Prof. 2010;30(3):187-196.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,080 Views
0 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs