Mayo Clinic, Neurology, Rochester, MN, USA.
East Carolina University, Greenville, NC, USA.
J Gen Intern Med. 2019 Jul;34(7):1131-1138. doi: 10.1007/s11606-019-04828-8. Epub 2019 Feb 12.
Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns.
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).
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.
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).
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.
医生的行为对高价值的医疗保健很重要，医学生在临床实习中遇到的学习环境可能会影响他们正在发展的实践模式。
通过（a）描述医学生的高值和低值行为，以及（b）考察与区域医疗保健强度（HCI）的关系，来探索临床实习中可能产生的影响。
多站点横断面调查
九所美国医学院的三、四年级学生
调查项目测量了高值（n=10）和低值（n=9）学生行为。区域 HCI 使用达特茅斯地图集生命末期慢性疾病护理数据（每例死亡患者的医生就诊次数与美国平均值的比值、医院护理强度指数、每例死亡患者的医学专科与初级保健医生就诊次数之比）进行测量。使用未调整和调整（控制年龄、性别和在校年级）的逻辑回归分析，使用中位数项目评分来总结报告的高值和低值行为的参与情况，来检验区域 HCI 与学生行为之间的关联。
在邀请的 2623 名学生中，有 1304 名（50%）做出了回应。许多学生报告试图确定医疗保健费用（1085/1234，88%），但只有 45%（571/1257）的学生报告在病例汇报中包含费用细节。学生承认仅仅是为了猜测他们的主管想要什么而建议进行检查（1143/1220，94%），炫耀自己能够做出广泛的鉴别诊断（1072/1218，88%），满足好奇心（958/1217，79%），保护团队免受责任追究（938/1215，77%），积累临床经验（533/1217，44%）。在医疗强度较高的地区，学生报告的低值行为明显更多：每增加一个单位的每例死亡患者的医生就诊次数，报告低值行为的几率增加 20%（OR 1.20，95%CI 1.04-1.38；P=0.01）。
三、四年级医学生报告了既包括高值行为又包括低值行为，这些行为与区域 HCI 有关。这突显了临床学习环境的重要性，并表明在医学院期间已经开始产生影响。
