a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands.
b Department of Public Health and Primary Care, Leiden University Medical Centre , Leiden , The Netherlands.
Teach Learn Med. 2019 Aug-Sep;31(4):402-411. doi: 10.1080/10401334.2019.1583566. Epub 2019 Mar 25.
Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, = 5; elderly care, = 8; family medicine, = 5; internal medicine, = 6; orthopedic surgery, = 6; surgery, = 6). An iterative grounded theory approach was used to analyze the qualitative data. Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.
医疗保健支出的不断增加威胁着医疗体系的可及性和负担能力。研究表明，当学习环境具有支持性时，教授（初级）医生提供高价值、具有成本意识的医疗服务是有效的。本研究旨在深入了解住院医师如何在工作场所学习提供高价值、具有成本意识的医疗服务，以及研究生培训环境如何影响这种学习。 2015 年 8 月至 2016 年 7 月，我们与来自六个住院医师培训项目（皮肤科、老年科、家庭医学科、内科、骨科、外科）的 36 名住院医师进行了六次同质焦点小组讨论。采用迭代扎根理论方法对定性数据进行分析。 影响高价值、具有成本意识的医疗服务提供学习的因素在三个层面上运作：个体住院医师、培训项目和工作场所。在个体层面上，我们发现了关于 HV3C 的三种类型的信念。在培训项目层面上，学习的感知决定因素包括住院医师与主管的互动、随着时间的推移参与决策以及接触不同的医疗服务提供。在工作场所层面上，学习取决于专业医疗保健专业知识的可用性和机构政策的存在。 住院医师在工作场所环境中努力抓住高价值、具有成本意识的医疗服务学习机会。住院医师培训项目和工作场所都可以为创造这些学习机会做出贡献。一个重要的起点是意识到住院医师的不同个人信念以及培训项目和工作场所层面上对高价值、具有成本意识的医疗服务的方法。
