Residency Training and Conservative Practice
Original Investigation Research
Invited Commentary
Celebrating Minimalism in Residency Training Deborah Korenstein, MD; Cynthia D. Smith, MD
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 Related article page 1640 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 environ-
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JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Purdue University User on 05/23/2015
1649
Research Original Investigation
Residency Training and Conservative Practice
ments that facilitates minimalism but did not identify what that something might be. Frustratingly little is known about the ways in which low-intensity and high-intensity environments differ, so it is challenging to identify important differences in the training environment. The best we can do is to postulate the knowledge, skills, and attitudes required to allow minimalism to flourish among physicians in training and to work toward addressing those factors through a variety of educational approaches and attempts to directly affect culture. To have the confidence to wait rather than act, physicians who use a minimalist approach need high-level knowledge of the comparative effectiveness of diagnostic tests and therapies and a strong understanding of disease prognosis. They need skills in clinical assessment and decision making, including the ability to estimate pretest probability and understand the difference between absolute and relative benefit, as well as communication skills to convey potential benefits and harms to patients and provide effective reassurance. Physicians also need to internalize a minimalist attitude and believe that more is not always better. In their study, Sirovich and colleagues4 controlled for overall physician knowledge as measured by the American Board of Internal Medicine certification examination, but this may be a poor measure of the knowledge required for minimalist practice. Although there are formal cur-
ricula addressing most of the components, the curricula are incompletely included in high-stakes tests, and many components remain challenging for trainees. The key to influencing knowledge, skills, and attitudes to foster minimalism may lie in addressing them in the informal curriculum (and the hidden curriculum, to the extent that it is possible) rather than in the formal curriculum. Instead of teaching skills in evidence interpretation in standalone curricula, educators should teach these skills during real-time patient care8 to emphasize their importance in real clinical practice. Furthermore, we can teach, demonstrate, and assess the use of high-quality, evidence-based, clinical decision–support tools; focus observations and feedback on each resident’s ability to interview and counsel patients in the real-world setting; and demonstrate minimalism during interactions with our own patients. Together, these approaches would help foster a shift toward minimalism and high-value care. We can only enhance the quality and value of the care delivered by our hospitals and practices if we change the behaviors of our new physicians. We need to go beyond financial incentives, cost awareness, and classroom teaching as we attempt to get physicians to do more of what is needed to improve patient outcomes and less of everything else.
2. Hackbarth G, Boccuti C. Transforming graduate medical education to improve health care value. N Engl J Med. 2011;364(8):693-695.
ARTICLE INFORMATION Author Affiliations: American College of Physicians, Philadelphia, Pennsylvania. Corresponding Author: Deborah Korenstein, MD, American College of Physicians, 190 N Independence Mall W, Philadelphia, PA 19106 ([email protected]). Published Online: September 1, 2014. doi:10.1001/jamainternmed.2014.3326. Conflict of Interest Disclosures: None reported. Disclaimer: The views expressed in this commentary do not reflect the official policy of the American College of Physicians. REFERENCES
3. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463. 4. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively [published online September 1, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.3337. 5. Asch DA, Nicholson S, Srinivas SK, Herrin J, Epstein AJ. How do you deliver a good obstetrician?
outcome-based evaluation of medical education. Acad Med. 2014;89(1):24-26. 6. Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403-407. 7. 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. 8. Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidenced-based medicine. BMC Med Educ. 2006;6:59. doi:10.1186/1472-6920-6-59.
1. Caverzagie KJ, Iobst WF, Aagaard EM, et al. The internal medicine reporting milestones and the next accreditation system. Ann Intern Med. 2013;158(7): 557-559.
1650
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Purdue University User on 05/23/2015
jamainternalmedicine.com
Original Investigation Research
Invited Commentary
Celebrating Minimalism in Residency Training Deborah Korenstein, MD; Cynthia D. Smith, MD
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 Related article page 1640 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 environ-
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Purdue University User on 05/23/2015
1649
Research Original Investigation
Residency Training and Conservative Practice
ments that facilitates minimalism but did not identify what that something might be. Frustratingly little is known about the ways in which low-intensity and high-intensity environments differ, so it is challenging to identify important differences in the training environment. The best we can do is to postulate the knowledge, skills, and attitudes required to allow minimalism to flourish among physicians in training and to work toward addressing those factors through a variety of educational approaches and attempts to directly affect culture. To have the confidence to wait rather than act, physicians who use a minimalist approach need high-level knowledge of the comparative effectiveness of diagnostic tests and therapies and a strong understanding of disease prognosis. They need skills in clinical assessment and decision making, including the ability to estimate pretest probability and understand the difference between absolute and relative benefit, as well as communication skills to convey potential benefits and harms to patients and provide effective reassurance. Physicians also need to internalize a minimalist attitude and believe that more is not always better. In their study, Sirovich and colleagues4 controlled for overall physician knowledge as measured by the American Board of Internal Medicine certification examination, but this may be a poor measure of the knowledge required for minimalist practice. Although there are formal cur-
ricula addressing most of the components, the curricula are incompletely included in high-stakes tests, and many components remain challenging for trainees. The key to influencing knowledge, skills, and attitudes to foster minimalism may lie in addressing them in the informal curriculum (and the hidden curriculum, to the extent that it is possible) rather than in the formal curriculum. Instead of teaching skills in evidence interpretation in standalone curricula, educators should teach these skills during real-time patient care8 to emphasize their importance in real clinical practice. Furthermore, we can teach, demonstrate, and assess the use of high-quality, evidence-based, clinical decision–support tools; focus observations and feedback on each resident’s ability to interview and counsel patients in the real-world setting; and demonstrate minimalism during interactions with our own patients. Together, these approaches would help foster a shift toward minimalism and high-value care. We can only enhance the quality and value of the care delivered by our hospitals and practices if we change the behaviors of our new physicians. We need to go beyond financial incentives, cost awareness, and classroom teaching as we attempt to get physicians to do more of what is needed to improve patient outcomes and less of everything else.
2. Hackbarth G, Boccuti C. Transforming graduate medical education to improve health care value. N Engl J Med. 2011;364(8):693-695.
ARTICLE INFORMATION Author Affiliations: American College of Physicians, Philadelphia, Pennsylvania. Corresponding Author: Deborah Korenstein, MD, American College of Physicians, 190 N Independence Mall W, Philadelphia, PA 19106 ([email protected]). Published Online: September 1, 2014. doi:10.1001/jamainternmed.2014.3326. Conflict of Interest Disclosures: None reported. Disclaimer: The views expressed in this commentary do not reflect the official policy of the American College of Physicians. REFERENCES
3. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463. 4. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively [published online September 1, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.3337. 5. Asch DA, Nicholson S, Srinivas SK, Herrin J, Epstein AJ. How do you deliver a good obstetrician?
outcome-based evaluation of medical education. Acad Med. 2014;89(1):24-26. 6. Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403-407. 7. 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. 8. Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidenced-based medicine. BMC Med Educ. 2006;6:59. doi:10.1186/1472-6920-6-59.
1. Caverzagie KJ, Iobst WF, Aagaard EM, et al. The internal medicine reporting milestones and the next accreditation system. Ann Intern Med. 2013;158(7): 557-559.
1650
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Purdue University User on 05/23/2015
jamainternalmedicine.com
