Residents’ Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study

Caroline L. Matchett, Hannah C. Nordhues, M. Usmaan Bashir, Stephen P. Merry, Adam P. Sawatsky

Research output: Contribution to journalArticlepeer-review


Background: Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). Objective: The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. Design: The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees’ IHE experiences to characterize their perceptions of HVCCC. Participants: The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. Approach: The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. Key Results: GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. Conclusions: IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees’ ideology of and commitment to HVCCC practices.

Original languageEnglish (US)
JournalJournal of general internal medicine
StateAccepted/In press - 2022


  • cost conscious care
  • high value care
  • International health electives

ASJC Scopus subject areas

  • Internal Medicine


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