Cynthia D. Smith

The Internal Medicine Reporting Milestones and the Next Accreditation System

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones Project to facilitate more synthetic and narrative-based assessments of educational outcomes. This commenta...

Evaluation of a novel assessment form for observing medical residents: a randomised, controlled trial

Context  Teaching faculty cannot reliably distinguish between satisfactory and unsatisfactory resident performances and give non‐specific feedback.

Early feedback on the use of the internal medicine reporting milestones in assessment of resident performance.

BACKGROUND The educational milestones were designed as a criterion-based framework for assessing resident progression on the 6 Accreditation Council for Graduate Medical Education competencies. OBJECTIVE We obtained feedback on, and assessed the construct validity and perceived feasibility and utility of, draft Internal Medicine Milestones for Patient Care and Systems-Based Practice. METHODS All participants in our mixed-methods study were members of competency committees in internal medicine residency programs. An initial survey assessed participant and program demographics; focus groups obtained feedback on the draft milestones and explored their perceived utility in resident assessment, and an exit survey elicited input on the value of the draft milestones in resident assessment. Surveys were tabulated using descriptive statistics. Conventional content analysis method was used to assess the focus group data. RESULTS Thirty-four participants from 17 programs completed surveys and participated in 1 of 6 focus groups. Overall, the milestones were perceived as useful in formative and summative assessment of residents. Participants raised concerns about the length and complexity of some draft milestones and suggested specific changes. The focus groups also identified a need for faculty development. In the exit survey, most participants agreed that the Patient Care and Systems-Based Practice Milestones would help competency committees assess trainee progress toward independent practice. CONCLUSIONS Draft reporting milestones for 2 competencies demonstrated significant construct validity in both the content and response process and the perceived utility for the assessment of resident performance. To ensure success, additional feedback from the internal medicine community and faculty development will be necessary.

Internal medicine milestones.

William Iobst, MD, is Vice President of Academic Affairs, American Board of Internal Medicine; Eve Aagaard, MD, is Associate Professor of Medicine, University of Colorado School of Medicine; Hasan Bazari, MD, is Program Director, Internal Medicine Residency Program, Massachusetts General Hospital, and Associate Professor of Medicine, Harvard Medical School; Timothy Brigham, MDiv, PhD, is Chief of Staff and Senior Vice President, Department of Education, Accreditation Council for Graduate Medical Education; Roger W. Bush, MD, is Attending Physician, Virginia Mason Medical Center; Kelly Caverzagie, MD, is Assistant Professor of Medicine and Associate Vice Chair for Quality and Physician Competence, Department of Internal Medicine, University of Nebraska Medical Center; Davoren Chick, MD, is Clinical Assistant Professor of Medicine, Department of Internal Medicine, University of Michigan Medical School; Michael Green, MD, is Professor of Medicine, Yale University School of Medicine; Kevin Hinchey, MD, is Associate Professor, Tufts University School of Medicine, and Chief Academic Officer, Baystate Medical Center; Eric Holmboe, MD, is Chief Medical Officer, American Board of Internal Medicine; Sarah Hood, MS, is Director of Academic Affairs, American Board of Internal Medicine; Gregory Kane, MD, is Professor of Medicine, Interim Chairman of the Department of Medicine, Jefferson Medical College; Lynne Kirk, MD, is Professor of Internal Medicine, University of Texas Southwestern Medical Center; Lauren Meade, MD, is Assistant Professor of Medicine, Tufts University School of Medicine, and Associate Program Director for Internal Medicine, Baystate Medical Center, and Chair of Educational Research Outcomes Collaborative–Internal Medicine; Cynthia Smith, MD, is Senior Medical Associate for Content Development, American College of Physicians, and Adjunct Associate Professor, Perelman School of Medicine; and Susan Swing, PhD, is Vice President, Outcome Assessment, Accreditation Council for Graduate Medical Education.

A practical framework for understanding and reducing medical overuse: Conceptualizing overuse through the patient-clinician interaction

&NA; Overuse of medical services is an increasingly recognized driver of poor‐quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert‐informed, evidence‐based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient‐clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation.

U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey.

Purpose To determine U.S. internal medicine (IM) residents’ knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments. Method The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age–sex–race–illness standardized measure of hospital days and inpatient physician visits by Medicare recipients). Results Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they “share estimated costs of tests and treatments with patients”; 15,549 of 17,626 (88.2%) agreed that they “incorporate patients’ values and concerns into clinical decisions.” Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital’s care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors. Conclusions U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents’ competency in providing value-based care.

SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve.

Medical students must learn how to practice high-value, cost-conscious care. By modifying the traditional SOAP (Subjective-Objective-Assessment-Plan) presentation to include a discussion of value (SOAP-V), we developed a cognitive forcing function designed to promote discussion of high-value, cost-conscious care during patient delivery. The SOAP-V model prompts the student to consider (1) the evidence that supports a test or treatment, (2) the patients preferences and values, and (3) the financial cost of a test or treatment compared to alternatives. Students report their findings to their teams during patient care rounds. This tool has been successfully used at 3 medical schools. Preliminary results find that students who have been trained in SOAP-V feel more empowered to address the economic healthcare crisis, are more comfortable in initiating discussions about value, and are more likely to consider potential costs to the healthcare system.

Celebrating Minimalism in Residency Training

As the US health care system strives to improve value, there is near universal agreement that medical trainees must learn to reduce waste. The Accreditation Council for Graduate Medical Education has included skills in cost consciousness in the 2013 internal medicine reporting milestones,1 the Medicare Payment Advisory Commission has recommended changes to graduate medical education to improve the economic viability of the US health care system,2 and a number of educational innovations to raise resident awareness of cost have been proposed. Despite enthusiasm for the notion of value among residents, junior physicians are overall greater users of health care resources than are older physicians,3 and residents’ ability to provide care that minimizes waste has not been, to our knowledge, previously described. In this issue of JAMA Internal Medicine, Sirovich and colleagues4 describe an association between the intensity of the training environment and clinical management decisions made by recent graduates. Using the 2007 American Board of Internal Medicine certification examination, they defined 2 subscales: one containing questions for which the correct response reflected appropriate conservative management, and the other containing questions for which the correct response reflected appropriate aggressive management. The investigators evaluated the association between examinee performance on each subscale and the aggressiveness of each examinee’s regional care environment as measured by the Endof-Life Visit Index, based on the mean number of physician visits (inpatient and outpatient) for Medicare beneficiaries in the last 6 months of life. After controlling for overall examination performance, Sirovich and colleagues4 found that the internists who were trained in less aggressive environments were more likely to correctly manage care conservatively compared with those who had trained in more aggressive environments and were equally likely to appropriately manage care aggressively. What do these findings tell us? First, they bolster the surprisingly thin evidence5 that training affects the way physicians care for patients. Second, the findings should reassure skeptics that it is possible to train residents to avoid overuse without leading them to underuse appropriately aggressive treatments. The question is how to strike this balance. Residency training influences physicians’ behavior through the formal curriculum (teaching in formal settings, such as educational conferences), the informal curriculum (teaching that occurs organically during patient care and other activities), the hidden curriculum (conveying of cultural norms),6 or through a combination of mechanisms. How can we explain the observed association between appropriate selection of conservative management and the intensity of the care in the training environment? In 2007, few educators were talking about health care value and no formal curricula had been described, so the observed difference must reflect teaching that took place in the informal and/or hidden curricula. The ways in which the informal and hidden curricula influence physician behavior are not clear, but they are almost certainly multifactorial. The factors relate to the many ways in which cultural norms of care are transmitted: through attending physicians who demonstrate by example the wisdom of watchful waiting in lieu of immediate testing, teaching attendings who regularly question trainees about the potential benefits and harms of their planned interventions, and senior trainees who express disapproval when students and interns propose overly aggressive care. These factors silently communicate the importance of conservative management and may help to create physicians who adopt a minimalist approach, justifying to themselves the net benefit of any intervention and erring on the side of not doing things in the absence of such justification. The challenge for educators is to tease apart the specific individual components of environmental factors and to design interventions that are needed to shift trainees’ beliefs and practices from the maximalist “more care is better care” mantra to a more minimalist approach. The minimalism associated with high-value care is different from cost consciousness. Many educational approaches to address value in both the formal and informal curricula have emphasized the importance of cost awareness when making medical decisions,7 and cost-effectiveness was the overarching focus of the Accreditation Council for Graduate Medical Education milestones related to value.1 Cost awareness is important and may help physicians opt for lower-intensity and lower-cost interventions, but cost is complex and difficult to accurately estimate. Furthermore, awareness of cost will not create physicians who embody minimalism and embrace conservative practice, and it is not likely to trump a strong environmental influence toward aggressive care. Minimalism is not about cost, nor is it overtly about the avoidance of harm. Rather, minimalism involves shifting the default setting away from interventions and toward conservative approaches, such as watchful waiting and patient reassurance. In addition, minimalism is a key component of high-value care. There are a handful of clinical situations in which trainees can improve value by learning to avoid the overuse of specific services, such as antibiotic therapy for upper respiratory tract infections or diagnostic magnetic resonance imaging for nonspecific lowback pain. Influencing these practices is important but will minimally impact a physician’s overall approach to care. Shifting the entire approach toward minimalism will influence all practice and will have a much greater effect on the overall quality of care and its cost. What would it take to shift the training system to nurture a more minimalist approach? Sirovich and colleagues4 found that there is something in low-intensity hospital environRelated article page 1640 Residency Training and Conservative Practice Original Investigation Research

R-SCAN: Why We Should Care!

INTRODUCTION The Radiology Support, Communication, and Alignment Network (R-SCAN) [1] is a 4-year effort of the ACR to empower 24,000 clinicians (4,000 radiologists and 20,000 referring clinicians) to advance stewardship in imaging care. As part of the CMS Innovation Center’s Transforming Clinical Practice Initiative [2], R-SCAN gives radiologists direct experience to transition to value-based care and to improve imaging utilization. A 2012 consensus report from the Institute of Medicine (IOM, now known as the National Academy of Medicine) indicates that an estimated

Harnessing the Power of Peer Pressure to Reduce Health Care Waste and Improve Clinical Outcomes

210 billion is spent annually on unnecessary medical services. IOM estimated that