is a Pediatric Hospitalist and Associate Residency Program Director.
All authors are with Children's Hospital Colorado and University of Colorado School of Medicine.
J Grad Med Educ. 2022 Feb;14(1):80-88. doi: 10.4300/JGME-D-21-00665.1.
The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described.
To explore pediatric residents' experiences with HVC and its facilitators and barriers.
We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached.
Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants.
Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.
研究生医学教育认证委员会要求住院医师将成本因素纳入患者护理中。然而，住院医师在临床环境中进行高价值医疗（HVC）的经验尚未得到很好的描述。
探讨儿科住院医师进行高价值医疗的经验及其促进因素和障碍。
我们采用扎根理论的方法对一家大型学术儿童医院的儿科住院医师进行了一项定性研究，通过电子邮件招募了他们作为研究对象。我们在 2020 年 2 月至 9 月期间进行了焦点小组（n=3）和访谈（n=7），使用半结构化指南进行。使用常规定量方法分析数据。使用迭代方法构建代码，并将其组织成主题类别。直到达到饱和状态才停止抽样。
22 名住院医师参与了研究。住院医师的基于价值的医疗保健决策发生在一个复杂的学习环境中。由于经验有限，住院医师担心漏诊，这导致了过度检测的现象。住院医师的自主权，加上有价值的经验学习，支持和阻碍了 HVC 的实施。通过患者护理讨论进行非正式教学；然而，缺乏成本信息。HVC 的实践因临床环境而异，在高急症和专科服务方面存在更大的挑战。对于患有复杂疾病的儿童，确定家庭关注和护理目标可以提高价值。家庭的经验/需求影响了住院医师的医疗保健决策，导致了高值和低值医疗的出现。医疗保健团队成员之间的有效合作至关重要；住院医师经常感到压力，因为他们认为顾问的低价值建议是不可接受的。
住院医师的 HVC 学习和实践受到复杂临床学习环境中多种因素的影响。
