Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity

Andrea N. Leep Hunderfund, Stephanie R. Starr, Liselotte (Lotte) Dyrbye, Elizabeth G. Baxley, Jed D. Gonzalo, Bonnie M. Miller, Paul George, Helen K. Morgan, Bradley L. Allen, Ari Hoffman, Tonya L. Fancher, Jayawant Mandrekar, Darcy A. Reed

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. Objectives: To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). Design: Multisite cross-sectional survey Participants: Third- and fourth-year students at nine US medical schools Main Measures: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. Key Results: Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04–1.38; P = 0.01). Conclusions: Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.

Original languageEnglish (US)
JournalJournal of general internal medicine
DOIs
StatePublished - Jan 1 2019

Fingerprint

Medical Students
Delivery of Health Care
Students
Physicians
Medical Schools
Clinical Clerkship
Learning
Exploratory Behavior
Aptitude
Imprinting (Psychology)
Surveys and Questionnaires
Atlases
Primary Care Physicians
Health Care Costs
Differential Diagnosis
Chronic Disease
Cross-Sectional Studies
Logistic Models
Regression Analysis
Medicine

Keywords

  • cost-conscious care
  • high-value cost-conscious care
  • medical students
  • survey
  • undergraduate medical education

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Imprinting on Clinical Rotations : Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity. / Leep Hunderfund, Andrea N.; Starr, Stephanie R.; Dyrbye, Liselotte (Lotte); Baxley, Elizabeth G.; Gonzalo, Jed D.; Miller, Bonnie M.; George, Paul; Morgan, Helen K.; Allen, Bradley L.; Hoffman, Ari; Fancher, Tonya L.; Mandrekar, Jayawant; Reed, Darcy A.

In: Journal of general internal medicine, 01.01.2019.

Research output: Contribution to journalArticle

Leep Hunderfund, Andrea N. ; Starr, Stephanie R. ; Dyrbye, Liselotte (Lotte) ; Baxley, Elizabeth G. ; Gonzalo, Jed D. ; Miller, Bonnie M. ; George, Paul ; Morgan, Helen K. ; Allen, Bradley L. ; Hoffman, Ari ; Fancher, Tonya L. ; Mandrekar, Jayawant ; Reed, Darcy A. / Imprinting on Clinical Rotations : Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity. In: Journal of general internal medicine. 2019.
@article{98ea2cf41dff43e687856270041cb627,
title = "Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity",
abstract = "Background: Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. Objectives: To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). Design: Multisite cross-sectional survey Participants: Third- and fourth-year students at nine US medical schools Main Measures: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. Key Results: Of 2623 students invited, 1304 (50{\%}) responded. Many reported trying to determine healthcare costs (1085/1234, 88{\%}), but only 45{\%} (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94{\%}), show off their ability to generate a broad differential diagnosis (1072/1218, 88{\%}), satisfy curiosity (958/1217, 79{\%}), protect the team from liability (938/1215, 77{\%}), and build clinical experience (533/1217, 44{\%}). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20{\%} (OR 1.20, 95{\%} CI 1.04–1.38; P = 0.01). Conclusions: Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.",
keywords = "cost-conscious care, high-value cost-conscious care, medical students, survey, undergraduate medical education",
author = "{Leep Hunderfund}, {Andrea N.} and Starr, {Stephanie R.} and Dyrbye, {Liselotte (Lotte)} and Baxley, {Elizabeth G.} and Gonzalo, {Jed D.} and Miller, {Bonnie M.} and Paul George and Morgan, {Helen K.} and Allen, {Bradley L.} and Ari Hoffman and Fancher, {Tonya L.} and Jayawant Mandrekar and Reed, {Darcy A.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1007/s11606-019-04828-8",
language = "English (US)",
journal = "Journal of General Internal Medicine",
issn = "0884-8734",
publisher = "Springer New York",

}

TY - JOUR

T1 - Imprinting on Clinical Rotations

T2 - Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity

AU - Leep Hunderfund, Andrea N.

AU - Starr, Stephanie R.

AU - Dyrbye, Liselotte (Lotte)

AU - Baxley, Elizabeth G.

AU - Gonzalo, Jed D.

AU - Miller, Bonnie M.

AU - George, Paul

AU - Morgan, Helen K.

AU - Allen, Bradley L.

AU - Hoffman, Ari

AU - Fancher, Tonya L.

AU - Mandrekar, Jayawant

AU - Reed, Darcy A.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. Objectives: To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). Design: Multisite cross-sectional survey Participants: Third- and fourth-year students at nine US medical schools Main Measures: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. Key Results: Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04–1.38; P = 0.01). Conclusions: Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.

AB - Background: Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. Objectives: To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). Design: Multisite cross-sectional survey Participants: Third- and fourth-year students at nine US medical schools Main Measures: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. Key Results: Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04–1.38; P = 0.01). Conclusions: Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.

KW - cost-conscious care

KW - high-value cost-conscious care

KW - medical students

KW - survey

KW - undergraduate medical education

UR - http://www.scopus.com/inward/record.url?scp=85061502801&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85061502801&partnerID=8YFLogxK

U2 - 10.1007/s11606-019-04828-8

DO - 10.1007/s11606-019-04828-8

M3 - Article

C2 - 30756307

AN - SCOPUS:85061502801

JO - Journal of General Internal Medicine

JF - Journal of General Internal Medicine

SN - 0884-8734

ER -