Habits start early. What is learned during training influences lifelong practice. This is true for medical students, residents and fellows in their medical practices as it is for all of us whose early experiences shape many of our lifetime behaviors. Hence, instilling the motivation and skills needed to promote high value care requires including new competencies into professional medical training through curriculum and practical experience.
At The UVM Medical Center, our trainees are receiving both. High value care curricula have been developed by professional societies such as the American College of Physicians (ACP) and Academic Alliance for Internal Medicine (AAIM) and are being used by our trainees to improve competency. Many residents have or are members of the teams for the programs I described in my last blog to reduce overuse and misuse of diagnostic tests and treatments of little or low value. Trainees will be part of each new project we undertake. In addition to helping design and implement change, the residents and fellows will present the results at local and national meetings and generate scholarly articles. This not only disseminates the practices we have found valuable here for use in other places, but enables the trainees to develop practical and scholarly skills.
The overall goal of our educational efforts is to influence knowledge, attitudes and behaviors for all parties striving to promote high value care.
It seems self-evident to say that as physicians we should only recommend tests or treatments that have “proven” value. Unfortunately, so much of what we do has not been tested in rigorous scientific studies that allow a practice to be labeled “evidence based.” The science of medicine at The UVM Medical Center and elsewhere is working hard to validate as many practices as possible. In the meantime, the art of medicine enables us to use current best practices, careful observation, experience and input from patients to use the best available information to direct patient care.
Many of us grew up in a medical culture that thought doing more was always better. Why not do the extra test, try some new treatment that sounds attractive or just different? More and more we are learning that the extra test my lead to misleading information. Something that looks abnormal on an X-ray may be an artifact but will require more tests to sort out the misinterpretation. This leads to added direct and indirect costs, inconvenience, discomfort, sometimes harm from complications of the tests and most of all anxiety patients and physicians.
Faculty development is important. We need not only to educate our trainees and other health care professionals but also re-educate the teachers, sometimes to unlearn. For all of us it is much harder to give up habits that we believe in than even to adopt new ones.
We must also engage forces outside of the traditional health care professional community that are influencing the practice of medicine. Those who pay the bills, insurers, and regulatory agencies concerned with patient safety and quality, mandate, encourage or prohibit practices. We as healthcare professionals and our trainees need to educate and work with these entities to ensure that such regulations do indeed further patient wellbeing rather than add to the hassle and cost of providing needed health care.
In medicine, knowledge is rapidly changing. With more than 8,000 papers published each day in the medical and scientific literature, it is hard for physicians and patients to keep up. More and more all members of the health care team need ongoing training to sift through the evidence and develop the skills to assist payers, patients and public to discard the obsolete and embrace current best practices.
Virginia L. Hood, MBBS, MPH, MACP, is a nephrologist at the University of Vermont Medical Center and a professor at the Larner College of Medicine at UVM.