Medical students may be more impressionable than other trainees as they are new to the clinical environment. While they are likely to observe and model themselves after physicians who deliver unnecessary services, they may also be influenced by experiences in value improvement. A focus on value at the student level could therefore be highly impactful, particularly if those efforts were student-led. Student-led initiatives can be challenging to implement for several reasons. Students lack the clinical knowledge, experience, and understanding of the local environment needed to create effective change and therefore need guidance and support from faculty and their institution. Additionally, formal curricula for teaching high value care implementation to medical students are lacking. Developing skills in quality improvement and understanding of cost are integral to these efforts. Given the importance of medical student training and engagement in high value care, we designed a student-led program to promote projects to de-implement unnecessary care at our institution.
The Student High Value Care (sHVC) longitudinal initiative centered on six core elements: (1) Student leadership, (2) Peer learning group, (3) Faculty mentorship, (4) Institutional support, (5) Value improvement curriculum, and (6) Scholarship. This program was open to all medical students at Icahn School of Medicine at Mount Sinai, and 21 students joined. Students were divided into three teams, and each team was paired with a faculty mentor. Initial participation was voluntary; no formal course credits were offered. The sHVC group met biweekly to monthly with meeting time split between the delivery of the Value improvement curriculum and discussion of progress and barriers to implementation. Each team met separately from the group weekly to monthly to work on its project.
The sHVC leadership (three students and two faculty directors) provided additional oversight. Teams averaged a 6:1 ratio of students to faculty, with additional mentorship provided by faculty co-directors (4:1). All junior faculty were provided mentorship by the senior faculty director. Curricular objectives focused on value improvement (PDSA cycles, understanding cost), leadership (Kotter’s 8 steps), and scholarship (Preparing an abstract). The Institute of Healthcare Delivery Science, and the electronic medical record group provided support for data collection and analysis. Medical directors and nursing managers helped with engagement among staff. The department also facilitated an expedited IRB review.
Each team had an ongoing project after the first year, utilizing plan-do-study-act cycles. All team interventions included student-led education and publicity campaigns with slogans, memes, and front-line engagement sessions. As one example, the team that targeted unnecessary folate lab testing created the slogan, “Don’t be a cereal orderer” to convey the message that folate deficiency is rare, and that daily needs can be replenished with a bowl of cereal. Their intervention included an awareness campaign where students personally distributing small boxes of cereal to residents and faculty, giving targeted feedback to providers, and changing EMR orders. This team decreased testing on all hospitalist patients admitted over 11 months by 48.5% (p<0.05) and resulted in projected $60,691 annual savings per year [see figure]. See table for additional details and results on projects.
The sHVC initiative is now in its second year, with additional twenty-six students and four teams. Eight abstracts were accepted at national conferences, including one oral presentation. In total, the initiative has over 50 students and faculty actively engaged in value improvement. This is now an elective course at Mount Sinai, and additional plans are in place to implement this program in other institutions.
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