Sticker shock: evaluation of a novel internal medicine clerkship high-value care curriculum using patient bills

Physician trainees receive limited formal education in high-value care (HVC) despite care costs being a high priority for patients. The authors evaluated the impact of a supplemental HVC curriculum, which exposed students to real health care costs for patients under their care, on understanding of health care cost determination, interest in HVC, and self-efficacy in advocating for patients.

Internal medicine clerkship students at the Perelman School of Medicine at the University of Pennsylvania were randomized between April 2023 and March 2024 to an intervention or control group. The intervention group obtained a postdischarge hospital bill for one patient and participated in a facilitated debrief session on billing and financial assistance resources. Students in the control group could opt to receive a bill but not the debrief. All students who obtained bills were asked to reflect on their findings. After clerkship completion, students were surveyed on their attitudes and planned behavior.

A total of 161 medical students completed the clerkship during the study, with 74 (46%) in the intervention group and 87 (54%) in the control group. All students agreed it was important for physicians to understand costs of care. Intervention group students were more likely to endorse improved understanding of how out-of-pocket costs were determined (47 of 53 [89%] vs 21 of 37 [57%], P < .001), confidence discussing costs on rounds (32 of 53 [60%] vs 14 of 37 [38%], P = .004), and plans to incorporate cost awareness into future practice (46 of 53 [87%] vs 23 of 37 [62%], P = .003).

This approach was the first to evaluate the use of patient bills in teaching medical students the financial ramifications of clinical behavior. Future work should explore how exposure to patient costs affects trainees' behaviors as they progress through training.