Despite increasing healthcare costs, training on cost-consciousness is lacking in graduate medical education (GME). Medical centers must consider how best to incorporate value-based training into their GME curricula. At the University of Chicago, we previously implemented the “Room of Horrors,” a simulation for entering interns to promote the detection of patient safety hazards. In this abstract, we describe a modification to this simulation to embed low-value hazards in addition to traditional patient safety hazards.
To incorporate low-value principles into an existing GME simulation exercise and assess incoming interns’ recognition of low-value care.
Choosing Wisely™ lists were reviewed to identify four low-value hazards to be embedded into the simulation in addition to the eight patient safety hazards used previously. These low-value hazards included: 1) arbitrary blood transfusion despite the patient’s stable hemoglobin (8.0 g/dL) and absence of cardiac symptoms 2) unnecessary stress ulcer prophylaxis (PPI) 3) placement of a Foley catheter without indication and 4) unnecessary use of restraints. Each intern was given ten minutes to read the door chart, inspect the simulation room, and write-down as many hazards as they could identify. Interns also completed a short survey on their prior training in medical school, and a follow-up survey one month into internship. T-tests were used to compare identification of low-value vs. safety hazards and to associate performance with prior training.
One hundred twenty-five entering PGY1 interns participated in the simulation, representing sixty medical schools and thirteen specialties. The mean percentage of hazards correctly identified was 50.4% (SD 11.8%). Interns identified significantly fewer low-value hazards (mean 19.2%, SD 18.6%) than safety hazards (mean 66.0%, SD 16.0%) (P < .001). For example, while 96% of interns identified the hand hygiene hazard, only 6% identified the unnecessary blood transfusion and none identified the unnecessary stress ulcer prophylaxis. Interns who self-reported as confident in their ability to identify hazards were not any more likely to correctly identify hazards than those who were not confident. One month after the simulation, 68.9% (82/119) of interns reported being more aware of how to identify hospital hazards, and 52.1% (62/119) had taken action during internship to reduce a potential hazard that was included in the simulation.
While many GME orientations include simulation and safety training, this exercise is the first of its kind to incorporate low-value care from Choosing Wisely™ recommendations into simulated training. Given the simulation’s low-cost and minimal material requirements, it could be easily integrated into existing training programs with the support of a simulation center. Our results suggest that interns are on the lookout for errors of omission (e.g. absence of hand hygiene, absence of isolation precautions), but are often blinded to errors of commission, such that when patients are started on therapies there is an assumption that the therapies are correct and necessary. These findings suggest poor awareness of low-value care among interns, and highlight a need for the prioritization and inclusion of value-based training in GME.
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