Incorporating the availability, but the complexity of reimbursement, in- measurement of these skills in high-stakes tests such surance-based cost differences, and the distinction be- as licensure and board certification examinations, tween costs and charges pose challenges. Electronic health records can facilitate price addressed by stand-alone curricula. Critical skills include expertise Hospital leaders must also ensure that clinicians in diagnostic reasoning and communication of benhave access to meaningful cost information during pa- efits and harms these are unlikely to be fully tient care. nancial arrangements with insurers, they are likely to beTo move forward, educators must better define come more conscious of value, which may lead to fun- the needed competencies for high-value care and credamental change. As more AMCs enter risk-sharing fi- will encourage further innovation. A performance categories in the ACGME (Accreditation long-term investment in value will benefit institutions Council for Graduate Medical Education) milestones and patients alike. Including the practice of cost-effective care among but a broader focus on preventing overuse is needed. At the resident level, there are Initiatives to reduce use of targeted high-cost services stand-alone curricula such as the AAIM-ACP (Alliance such as magnetic resonance imaging scans can help, for Academic Internal Medicine American College of Physicians) High-Value Cost-Conscious Care Curriculum,7 resident-led qualityimprovement initiatives, online costs Trainees must understand that the of care videos (produced by the nonprimary goal is optimal patient profit Costs of Care), and novel costconscious clinical conferences, which outcomes, not knowledge for its own provide the actual costs of every test sake. Leaders Choosing Wisely lists) into learning cases for students must balance legitimate length-of-stay needs against and student-faculty colearning, through qualityovertesting, and explicitly discuss both issues with staff. Curricurently, financial margins may motivate some hospital lar innovations include integrating recommendations leaders to emphasize early patient discharge, which may about potentially overused tests and procedures encourage simultaneous ordering of first- and second- (American Board of Internal Medicine Foundation line tests to save time and limit hospital days. Cur- which speakers describe relevant value issues. An emphasis The Role of Institutional Leadership Institutional leaders such as department chairs, deans, on value has been incorporated into departmental and hospital chief medical officers must strongly and con- educational conferences such as grand rounds, during sistently support efforts to improve value of care. Educators have begun developing innovative approaches to teaching students and residents about high-value care using a variety of tools. Educational leaders must now define a new model that balances the benefits of necessary tests and treatments against the harms of those that are not needed. These views persist in 2012 clinical chairs at an AMC agreed that “residents need to order a lot of tests in order to learn” (W.L., oral communication, September 2012). Often academic educators have emphasized completeness, focusing on the generation of exhaustive differential diagnoses with little emphasis on diagnoses for which testing should not be done. The importance of improving the value of care in academic medical centers (AMCs) and teaching trainees about value are widely accepted.3,4 AMCs are particularly critical because they shape the future clinical behaviors of physicians.5 In this Viewpoint, we discuss important steps to shift AMCs toward a culture of high-value care.Įducators have encouraged low-value care in the past and they now must play a central role in improving value. Defensive medicine, fragmented care, misaligned financial incentives, and cultural factors1,2 are all associated with low-value care. Low-value care can be defined as care for which harms, defined in terms of resource use, financial expenditure, or patient harm, outweigh clinical benefits. Teaching Value in Academic Environments Shifting the Ivory Tower In the United States, low-value care is a pervasive problem. Wendy Levinson, MD Department of Medicine, University of Toronto, Toronto, Ontario, Canada.Ĭorresponding Author: Deborah Korenstein, MD, American College of Physicians, 190 N Independence Mall W, Philadelphia, PA 19106-1572 (. Minal Kale, MD, MPH Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. Deborah Korenstein, MD American College of Physicians, Philadelphia, Pennsylvania.
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