Tips for Teaching High Value Care on Rounds     Emily Zarookian, MD

Teaching high value care in medical education is an essential, although recent addition to many graduate and undergraduate medical education curriculums. High value care has become an essential part of medical education as healthcare expenditures continue to rise with up to 30% ($765 billion) of those costs identified as potentially avoidable costs. 1

As teaching high value care can be a new skill for many seasoned attendings physicians it is not surprising that multiple studies have found a lack of teaching high value care on rounds. One study found that only in 20% of observed rounding episodes was there any discussion of high value test ordering principles.2

The following two exercises are examples of easy to use exercises on rounds to emphasize the principles of high value care.

Exercises to use on rounds:

Ask the “five questions” before ordering tests.

The American College of Physicians published five questions physicians should ask before ordering tests.3 Choose one patient on daily rounds and ask the team these five questions before ordering a test.

  1. Whether a diagnostic test other than a CBC, BMP, CMP, or INR was previously performed
  2. Whether diagnostic test results would affect care
  3. Whether a test result represented- or a study under consideration might produce a false positive result
  4. Whether the patient would experience short-term harm if a test were not ordered
  5. Whether the team considered patient preferences towards a diagnostic study

Focus on “Choosing Wisely”

 Select one of the Hospital Medicine “Choosing Wisely” initiatives for the week. Focus on this initiative by asking one team member to track progress throughout the week on decreasing utilization of unnecessary foley catheters, low utility telemetry, or repetitive daily labs. Report progress daily.

Society of Hospital Medicine “Choosing Wisely” 

  1. Don’t place, or leave in place urinary catheters for incontinence, convenience, or monitoring of output for non-critically ill patients.  Suggest team members track foley catheters using EHR to remind team members which patients have foley catheters in place
  2.  Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications
  3.  Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of  active coronary disease, heart failure or stroke.
  4. Don’t order continuous telemetry monitoring without using a protocol that governs continuation
  5. Don’t perform repetitive CBC, CMP in the face of clinical and lab stability.  Suggestion: use comparemaine.org to quickly review the costs of tests and procedures at different facilities in Maine. This        will give learners insight into how expensive unnecessary daily labs can be.

 Additional Resources

  1. JAMA Internal Medicine Teachable Moments Series : Short, easy to read articles that each begin with a clinical vignette in which unnecessary care resulted in patient harm followed by a quick evidence based review of the subject. This series is first authored by learners. Consider encouraging a learner to submit a “teachable moment” if occurs.

References:

  1. Smith, Cynthia MD et al. “Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine- American College of Physicians Curriculum.” Annals of Internal Medicine. 2012; 157:284-286.
  2. Pierce Cason MD et al. “ Frequency of Attending Physician-Led Discussion of Test-Ordering Principles during Teaching Rounds” JAMA Internal Medicine. 2016; 176:2:261-262
  3. Qaseem  A, Alguire  P, Dallas  P,  et al.  Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156(2):147-149.
Download PDF