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Current and Optimal Training in High-Value Care in the Internal Medicine Clerkship: A National Curricular Needs
Danelle Cayea1, Kim Tartaglia, Amit Pahwa
1D. Cayea is associate professor of medicine, Division of Geriatric Medicine and Gerontology, and associate vice chair for education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; ORCID: http://orcid.org/0000-0003-2061-2007. K. Tartaglia is associate professor of medicine and associate director of hospital medicine, Division of Hospital Medicine, Ohio State University, Columbus, Ohio. A. Pahwa is assistant professor of medicine and director, Johns Hopkins Hospital Medicine Sub-Internship, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. H. Harrell is professor of medicine and codirector, Internal Medicine Clerkship, Division of General Internal Medicine, University of Florida, Gainesville, Florida. A. Shaheen is professor of clinical medicine and codirector, Longitudinal Integrated Clerkship, Ambulatory, University of North Carolina School of Medicine, Chapel Hill, North Carolina. V.J. Lang is associate professor of medicine, director of the medicine subinternship, and senior associate division chief, Hospital Medicine Division, University of Rochester School of Medicine & Dentistry, Rochester, New York.
Purpose:
The clinical skills needed to practice high-value care (HVC) are core to all medical disciplines. Medical students form practice habits early, and HVC instruction is essential to this formation. The purpose of this study was to describe the state of HVC instruction and assessment in internal medicine clerkships and identify needs for additional curricula.
Method:
In 2014, the Clerkship Directors in Internal Medicine conducted its annual survey of 121 U.S. and Canadian medical schools. The authors evaluated a subset of questions from that survey asking clerkship directors about the perceived importance of HVC instruction, type and amount of formal instruction and assessment, achievement of student competence, prioritization of topics, and barriers to curriculum implementation. Descriptive statistics were used to summarize responses, and chi-square tests were used to examine associations between response categories.
Results:
The overall response rate was 77.7% (94/121). The majority (85; 91.4%) agreed that medical schools have a responsibility to teach about HVC across all phases of the curriculum. Of respondents, 31 (32.9%) reported their curricula as having some formal instruction on HVC, and 66 (70.2%) felt the amount was inadequate. Highest-priority topics for inclusion included overuse of diagnostic tests and treatments, defining value and its application to clinical reasoning, and balancing benefit and harm. Only 11 (17.8%) assessed students' competence in HVC.
Conclusions:
Internal medicine clerkship directors reported that HVC is insufficiently taught and assessed in medical school, despite relevance to practice. Developing generalizable curricular materials, faculty development, and dedicated curricular time may enhance HVC education.
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