Improving Educational Interventions for Physicians to Provide High-Value, Cost-Conscious Care

Educational interventions to improve the provision of high-value, cost-conscious care by physicians are more effective by combining specific knowledge transmission, reflective practice, and a supportive environment, according to a study in the December 8 issue of JAMA, a theme issue on medical education.1
Increasing costs of health care are a cause of concern to patients, governments, and the medical profession around the world. The United States has the highest health care expenses, with health care expenditures in 2015 approaching 18 percent of gross domestic product. Interventions targeting physicians and their medical expertise are proposed as a means to reduce health care waste (care that is not beneficial to patients) while maintaining the quality of care, according to background information in the article.
Lorette A. Stammen, M.D., of Maastricht University, Maastricht, the Netherlands, and colleagues examined how and under what circumstances educational interventions may help practicing physicians, resident physicians, and medical students deliver high-value, cost-conscious care. The study consisted of a review of 79 studies that included educational interventions on this topic.
Of the 79 studies, 14 were randomized clinical trials, of which 12 addressed knowledge transmission, 7 reflective practice, and 1 supportive environment; 10 (71 percent) concluded that the intervention was effective. The data analysis suggested that 3 factors aid successful learning:
Effective transmission of knowledge, related, for example, to general health economics and prices of health services, to scientific evidence regarding guidelines and the benefits and harms of health care, and to patient preferences and personal values (67 articles);
Facilitation of reflective practice, such as providing feedback or asking reflective questions regarding decisions related to laboratory ordering or prescribing to give trainees insight into their past and current behavior (56 articles);
Creation of a supportive environment in which the organization of the health care system, the presence of role models of delivering high-value, cost-conscious care, and a culture of high-value, cost-conscious care reinforce the desired training goals (27 articles).
“These 3 factors combined provide a framework for the development and further research of educational programs that teach physicians to deliver high-value, cost-conscious care,” the authors write.
“Although the reported effectiveness of educational interventions seems to provide scope for medical education to bring about improvement, training physicians to deliver high-value, cost-conscious care remains a complex task. Further research should focus on what makes a good role model of high-value, cost-conscious care and how such attributes can be cultivated by means of medical education.”
“Additionally, there is a need to investigate how formal education can help mold the culture of the learning environment. Although measuring the value of care is extremely complex, outcome measures that focus solely on volume or costs might promote the incorrect assumption that cheaper is better. Therefore, thoughtful consideration of which outcome measures can be used to evaluate the effectiveness of interventions remains important.”
Deborah Korenstein, M.D., of the Memorial Sloan Kettering Cancer Center, New York, writes in an accompanying editorial that a large challenge involves designing educational approaches that acknowledge the complexity of high-value clinical care and characterizing educational end points that reflect generalizable skills.2
“High-value clinical care is not one skill: its mastery requires a variety of teaching approaches and outcome measures. Thus far, approaches have generally been narrow, have often focused on cost, and have involved freestanding curricula as opposed to integration.”
“The education community must now develop novel curricula, meaningful assessment tools for curriculum evaluation, and measurable milestones that move beyond cost issues. These activities may provide the path to lead physicians toward the practice of high-value care.”
1. doi:10.1001/jama.2015.16353; 
2. doi:10.1001/jama.2015.15406;