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Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences With Cost-Conscious Care

Leep Hunderfund, Andrea N. MD, MHPE; Dyrbye, Liselotte N. MD, MHPE; Starr, Stephanie R. MD; Mandrekar, Jay PhD; Naessens, James M. ScD; Tilburt, Jon C. MD, MPH; George, Paul MD, MHPE; Baxley, Elizabeth G. MD; Gonzalo, Jed D. MD, MSc; Moriates, Christopher MD; Goold, Susan D. MD; Carney, Patricia A. PhD; Miller, Bonnie M. MD; Grethlein, Sara J. MD; Fancher, Tonya L. MD, MPH; Reed, Darcy A. MD, MPH

doi: 10.1097/ACM.0000000000001223
Research Reports
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Purpose To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care.

Method Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index.

Results Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001).

Conclusions Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.

A.N. Leep Hunderfund is assistant professor of neurology, Mayo Clinic, Rochester, Minnesota.

L.N. Dyrbye is professor of medical education and medicine, Mayo Clinic, Rochester, Minnesota.

S.R. Starr is assistant professor of pediatric and adolescent medicine and director, Science of Health Care Delivery Education, Mayo Medical School, Mayo Clinic, Rochester, Minnesota.

J. Mandrekar is professor of biostatistics and neurology, Mayo Clinic, Rochester, Minnesota.

J.M. Naessens is professor of health services research, Mayo Clinic, Rochester, Minnesota.

J.C. Tilburt is professor of medicine and associate professor of biomedical ethics, Mayo Clinic, Rochester, Minnesota.

P. George is associate professor of family medicine and associate professor of medical science, Warren Alpert Medical School, Brown University, Providence, Rhode Island.

E.G. Baxley is professor of family medicine and senior associate dean of academic affairs, Brody School of Medicine, East Carolina University, Greenville, North Carolina.

J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Pennsylvania State University College of Medicine, Hershey, Pennsylvania.

C. Moriates is assistant clinical professor, Division of Hospital Medicine, and director, Caring Wisely Program, University of California San Francisco, San Francisco, California.

S.D. Goold is professor of internal medicine and health management, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan.

P.A. Carney is professor of family medicine and of public health and preventive medicine, Oregon Health & Science University, Portland, Oregon.

B.M. Miller is professor of medical education and administration, professor of clinical surgery, associate vice chancellor for health affairs, and senior associate dean for health sciences education, Vanderbilt University, Nashville, Tennessee.

S.J. Grethlein is professor of clinical medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.

T.L. Fancher is associate professor of medicine, Division of General Medicine, University of California Davis, Sacramento, California.

D.A. Reed is associate professor of medical education and medicine and senior associate dean of academic affairs, Mayo Medical School, Mayo Clinic, Rochester, Minnesota.

Funding/Support: This study was prepared with financial support from the American Medical Association as part of the Accelerating Change in Medical Education initiative, and all participating schools received grants through this initiative (see www.changemeded.org for further details). The content of this article reflects the views of the authors.

Other disclosures: A.N. Leep Hunderfund reported a grant from the American Board of Psychiatry and Neurology and royalties from the American Association for Neuromuscular and Electrodiagnostic Medicine for the sale of “Real EMG” online modules, outside the present work. P. George reported grants from the National Institutes of Health, Health Resource Services Administration, Rhode Island Foundation, American Board of Internal Medicine, and Substance Abuse and Mental Health Services Administration, outside the present work. C. Moriates reported grants from the ABIM Foundation for work on the Teaching Value Project and royalties from McGraw-Hill for authoring the textbook Understanding Value-Based Healthcare, outside the present work. T.L. Fancher reported grants from the Health Resource Services Administration, outside the present work. The other authors reported that they had no disclosures.

Ethical approval: The name of the reviewing body, reference number, and date of approval/exemption for each participating school are as follows: Warren Alpert Medical School of Brown University institutional review board, review not required given approval by Mayo Clinic institutional review board, 9/2/2014; East Carolina University and Medical Center institutional review board, UMCIRB 13-002004, 10/1/2014; University of California, San Francisco institutional review board, 14-14833, 10/8/2014; University of California, Davis institutional review board, 703042-1, 1/22/2015; Indiana University institutional review board, 1408873140, 8/22/2014; Mayo Clinic institutional review board, 14-005115, 7/23/2014; University of Michigan institutional review board, HUM00095266, 12/2/2015; Oregon Health & Science University institutional review board, #11026, 9/6/2014; Pennsylvania State University institutional review board, STUDY00000773, 8/28/2014; Vanderbilt University institutional review board, 150073, 1/19/2015.

Previous presentations: These data were presented at the American Medical Association ChangeMedEd Conference, October, 2, 2015, Chicago, Illinois, and at the Alliance for Academic Internal Medicine 36th Annual Academic Internal Medicine Educational Conference, October 9, 2015, Atlanta, Georgia.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A357 and http://links.lww.com/ACADMED/A358.

An AM Rounds blog post on this article is available at academicmedicineblog.org.

Correspondence should be addressed to Andrea Leep Hunderfund, Mayo Clinic, Neurology, 200 First St. SW, Rochester, MN 55905; telephone: (507) 284-4006; e-mail: leep.andrea@mayo.edu.

Physicians have a professional obligation to provide effective care through prudent stewardship of public and private health care resources.1 However, up to 30% of health care spending in the United States is wasted, and a major source of waste is unnecessary health care services.2 Overuse of tests and procedures increases costs and reduces quality of care by exposing patients to unnecessary risk,3 burdening them with out-of-pocket expenses,4,5 and displacing or delaying care they actually need.6 Health care intensity—that is, the number and types of services that patients receive—is determined, in part, by physician behaviors.7 Thus, many efforts to reduce health care costs focus on educating, supporting, and incentivizing physicians to provide high-value, cost-conscious care.5,8–10 Further, medical educators must prepare trainees to control costs and protect the financial well-being of their patients and health care systems.11–15 To succeed in such efforts, a multifaceted approach that considers the formal curriculum as well as the broader learning environment is recommended.16–19

Recent studies have shown that the spending patterns20 and health care intensity21,22 that physicians experience during training are associated with their subsequent knowledge,22 attitudes,21 and behaviors20 related to cost-conscious care. These findings suggest that the learning environment may influence trainees’ future practice patterns. Role modeling is a salient aspect of the learning environment23–26 and may be one mechanism whereby the learning environment affects the professional development of trainees.27 However, to our knowledge, no studies have explored the relationship between regional health care intensity and the physician behaviors that learners observe related to cost-conscious care. Furthermore, although medical school is a pivotal time in the professional development of physicians,23,28 no large, multicenter studies have examined the attitudes and experiences of medical students related to cost-conscious care. The objectives of this study were to (1) examine U.S. medical student attitudes toward cost-conscious care and (2) determine whether students’ reported exposure to cost-conscious or potentially wasteful role-modeling behaviors is related to health care intensity in the region of their medical school.

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Method

Study design and participants

We conducted a cross-sectional survey of all students at 10 U.S. medical schools accredited by the Liaison Committee on Medical Education: Warren Alpert Medical School of Brown University; Brody School of Medicine at East Carolina University; University of California, San Francisco School of Medicine; University of California, Davis School of Medicine; Indiana University School of Medicine; Mayo Medical School; University of Michigan Medical School; Oregon Health & Science University School of Medicine; Pennsylvania State University College of Medicine; and Vanderbilt University School of Medicine. These schools are recipients of an American Medical Association (AMA) Accelerating Change in Medical Education grant29 and have variable class sizes, geographic locations, private/public status, and missions. All students were invited to participate because most contemporary medical school curricula (including the curricula at all participating schools) incorporate clinical experiences beginning in the first year. The institutional review board (IRB) at each school approved or exempted this study.

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Survey instrument

Survey items measured student attitudes toward cost-conscious care (n = 13), perceived barriers to and consequences of cost-conscious care (n = 9), and reported exposure to physician role-modeling behaviors related to cost-conscious care (n = 13). Survey items were pilot-tested with medical students and modified on the basis of their feedback. (The survey instrument is available as Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A357.)

Items assessing student attitudes toward cost-conscious care were derived from previously published surveys of practicing physicians30–34 and the AMA Council on Ethical and Judicial Affairs report on physician stewardship of health care resources.1 Items assessing perceived barriers to and consequences of cost-conscious care were derived from published surveys of practicing physicians31,34 and a review of the literature.35–44 For these items, students were asked to indicate their extent of agreement using a four-point Likert scale (1 = strongly disagree, 2 = moderately disagree, 3 = moderately agree, 4 = strongly agree), consistent with previous surveys of physicians.33,34

Items assessing student exposure to physician role-modeling behaviors related to cost-conscious care were developed by the investigators on the basis of the literature.14,15,33,42,45–48 We classified these role-modeling behaviors a priori as cost-conscious (seven items) if they generally promoted less intense use of health care resources and as potentially wasteful (six items) if they generally promoted more intense use of health care resources. Students were asked to use a four-point scale to indicate how often in the past year they had observed a physician performing each behavior (0 = never, 1 = rarely [1–2 times], 2 = sometimes [3–5 times], 3 = often [6 or more times]).

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Data collection

We e-mailed a letter to students between January and March 2015, inviting them to participate in the study. The letter indicated that participation was voluntary and that responses would be anonymous, and it included a link to the electronic survey, which was distributed using the Qualtrics survey platform. Up to three e-mailed reminders were sent to nonresponders. Informed consent was implied upon survey completion. Students at nine of the participating medical schools were given an opportunity to enter a lottery to win a $250 cash card as an incentive for participation. The IRB at one school did not allow an incentive.

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Regional health care intensity

We measured regional health care intensity (the number and types of services patient receive) using hospital referral region (HRR)-level per capita data from the Dartmouth Atlas of Health Care’s End-of-Life Chronic Illness Care database.49 These data reflect care intensity during the last two years of life for Medicare beneficiaries aged 67 years or older with chronic illnesses who died in 2012 (termed “decedents”). We used end-of-life data to compare the intensity of care provided to a cohort of comparably ill patients with a life expectancy of exactly two years.22 We used regional rather than hospital-level data because most students train at more than one hospital (usually in close proximity). We considered the primary HRR for each medical school to be the HRR encompassing the majority of hospitals where students from that school rotated during the 2014–2015 academic year.

We measured health care intensity in the primary HRR associated with each medical school using the ratio of physician visits per decedent within a given HRR to the average number of physician visits per decedent in the United States, the ratio of medical specialty to primary care physician visits per decedent, and the hospital care intensity index (a composite measure of hospital days and inpatient physician visits)—all adjusted for age, sex, race, and chronic condition. We selected these measures of health care intensity on the basis of the premise that they would be more visible to students than direct measures of spending22 and because health care resource utilization among Medicare beneficiaries has been shown to reflect health care intensity among commercially insured patients50 and Medicaid beneficiaries51 in the same region.

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Data analysis

Response rates were reported using the American Association for Public Opinion Research response rate 2 definition.52 The age, sex, and year in school of respondents were compared with those of the total sampled population. Descriptive summary statistics were reported as means with standard deviations (SDs) or frequencies with percentages, as appropriate. Differences among proportions were evaluated using the Pearson χ2 test. To summarize student exposure to role-modeling behaviors, we created two role-modeling scales: one for cost-conscious role-modeling behaviors (from the relevant seven items, with possible scores ranging from 0 to 21) and one for potentially wasteful behaviors (from the relevant six items, with possible scores ranging from 0 to 18). These scales had raw Cronbach alphas of 0.82 and 0.81, respectively, indicating good internal consistency reliability.53 We calculated scores on each scale by summing students’ responses to items on the scale, including only responses from students who had answered all items within a given scale. Scores on these scales were then used as dependent variables in unadjusted and adjusted (controlling for sex and year in school) linear regression models examining associations with regional health care intensity.

All tests were two sided, and P values < .05 were considered statistically significant. No imputations were done for missing data. We conducted sensitivity analyses excluding responses from students who were not offered an incentive for participation. The false discovery rate approach was used to correct for multiple comparisons. Analyses were performed using SAS version 9.3 (SAS Institute, Cary, North Carolina).

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Results

Of the 5,992 medical students invited to participate, 3,395 (57%) responded. Response rates at the 10 participating schools ranged from 40% to 75% (median 58%). The distributions of respondents with respect to sex, age, and year of training were similar to those of the overall sample (Table 1) and U.S. medical students in general.54

Table 1

Table 1

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Attitudes toward cost-conscious care

While only 63% (1,867/2,955) of students agreed (moderately or strongly) that physician clinical practices such as ordering and prescribing are key drivers of health care costs, 90% (2,640/2,932) agreed that trying to contain costs is the responsibility of every physician (Table 2). Nearly all students agreed that physicians should take a more prominent role in limiting the use of unnecessary tests (2,896/3,003; 96%) and should be aware of the costs of the tests or treatments they recommend (2,920/3,000; 97%). Most also agreed that costs to society should be important in physician decisions (2,062/2,951; 70%) and that managing health care resources for all patients is compatible with physicians’ obligation to serve individual patients (2,343/2,926; 80%).

Table 2

Table 2

First- and second-year students were significantly more likely than third- and fourth-year students to agree that the cost of a test or medication is only important if the patient has to pay for it out of pocket (233/1,427 [16%] vs. 149/1,421 [10%], P < .001); that it is unfair to ask physicians to be cost-conscious and still keep the welfare of their patients foremost in their minds (461/1,425 [32%] vs. 388/1,421 [27%], P = .008); that physicians should talk to patients about the costs of care when discussing treatment options (1,353/1,433 [94%] vs. 1,242/1,422 [87%], P < .001); and that physicians should provide tests or treatments if a patient requests them (411/1,432 [29%] vs. 163/1,424 [11%], P < .001; see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A358).

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Perceived barriers to and consequences of cost-conscious care

Nearly all students agreed (moderately or strongly) that eliminating unnecessary tests and procedures will improve patient safety (2,700/2,935; 92%), and most disagreed (moderately or strongly) that spending more money on health care leads to better health outcomes (2,577/2,931; 88%; Table 2). However, 34% (995/2,947) agreed that doctors are too busy to worry about costs, and only 11% (344/3,032) agreed that it is easy to determine how much tests and procedures cost. Fifty-eight percent (1,685/2,928) agreed that ordering fewer tests and procedures will increase physicians’ risk of malpractice litigation, 48% agreed that it is easier to order a test than to explain to a patient why it is unnecessary (1,416/2,960), and 23% (686/2,947) agreed that patients will be less satisfied with care provided by physicians who discuss costs. Approximately one of every six students (482/2,931; 16%) agreed that practicing cost-conscious care will undermine patients’ trust in physicians.

Third- and fourth-year students were more likely than first- and second-year students to endorse barriers to cost-conscious care (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A358). Specifically, third- and fourth-year students were more likely than first- and second-year students to agree that it is easier to order a test than explain to the patient why it is unnecessary (726/1,425 [51%] vs. 624/1,432 [44%]) and that the organizational culture at their institution makes it difficult for doctors to address costs of care (796/1,425 [56%] vs. 560/1,424 [39%]; both P < .001). Furthermore, they were less likely to agree that it is easy to determine how much tests and procedures cost (110/1,420 [8%] vs. 210/1,416 [15%]) and that spending more money on health care leads to better health outcomes (134/1,420 [9%] vs. 207/1,430 [14%]; both P < .001).

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Reported exposure to physician role-modeling behaviors related to cost-conscious care

Most students reported observing cost-conscious role-modeling behaviors at least once in the past year, such as a physician explaining to a patient why a particular test is not necessary (2,804/3,073; 91%), discussing costs of care with students or health care team members when making care decisions (2,736/3,070; 89%), or pointing out examples of waste in the health care system (2,748/3,072; 89%; Table 3). Most students also reported observing potentially wasteful role-modeling behaviors at least once in the last year, such as a physician ordering numerous tests all at once rather than waiting to see the results of initial screening tests (2,339/3,136; 75%) or repeating tests rather than attempting to obtain recently performed test results (2,249/3,134; 72%). Many students reported seeing a physician make an unnecessary referral (2,042/3,137; 65%) or order a more expensive test or treatment (1,790/3,136; 57%) in response to a patient request. Forty-five percent (1,361/3,049) reported never having seen a physician praise a trainee for ordering a cost-effective diagnostic workup, whereas 42% (1,292/3,056) reported observing a physician criticize a trainee at least once during the past year for failing to order routine daily labs on a stable hospitalized patient.

Table 3

Table 3

The mean score on the cost-conscious role-modeling scale was 12 (SD 4.7; range 0–21; n = 3,015 students). The mean score on the potentially wasteful role-modeling scale was also 12 (SD 4.0; range 0–18; n = 3,204 students).

Third- and fourth-year students reported observing all cost-conscious and potentially wasteful physician role-modeling behaviors significantly more often than first- and second-year students (all P < .001; see Supplemental Digital Appendix 3 at http://links.lww.com/ACADMED/A358).

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Relationship between regional health care intensity and reported exposure to physician role-modeling behaviors

There were no significant differences in our measures of health care intensity between HRRs that were (n = 10) and were not (n = 297) associated with a participating medical school (Table 4). Students training in regions with higher health care intensity reported observing significantly fewer cost-conscious role-modeling behaviors (Table 5). This relationship was strongest for the ratio of physician visits per decedent within the HRR compared with the U.S. average, followed by the hospital care intensity index and the ratio of medical specialty to primary care visits per decedent. For each one-unit increase in these three measures of health care intensity, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (standard error [SE] 0.7), 3.9 (SE 0.6), and 3.2 (SE 0.6) points, respectively, in adjusted analyses controlling for sex and year in school (all P < .001). Measures of regional health care intensity were not significantly associated with reported exposure to potentially wasteful role-modeling behaviors in unadjusted or adjusted analyses. These findings did not change when responses from students who were not offered an incentive for participation were excluded (data not shown).

Table 4

Table 4

Table 5

Table 5

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Discussion

This large, multisite survey study demonstrates that U.S. medical students generally agree with the concept of stewardship and believe that physicians should consider and try to contain costs when caring for patients. They recognize that excess testing and unnecessary procedures threaten patient safety and that spending more money on health care does not necessarily lead to better health outcomes. However, students also perceive barriers to cost-conscious care and observe conflicting physician role-modeling behaviors in the learning environment, which are related to measures of regional health care intensity.

Student perceptions of the learning environment are strongly related to the role-modeling behaviors they observe.25,55 Encouragingly, the majority of students in this study reported observing cost-conscious physician role-modeling behaviors. However, many students also reported observing potentially wasteful role-modeling behaviors such as excessive use of diagnostic tests and unnecessary referrals, which may erode values taught in more formal settings25,44 and adversely affect students’ intended55 and actual56 behaviors.

As would be expected, third- and fourth-year students reported greater exposure to physician role-modeling behaviors than first- and second-year students, and their responses suggest a greater awareness of how physician behaviors affect the broader health care system. However, third- and fourth-year students also perceived more barriers to cost-conscious care. Several innovative curricula have been developed to equip trainees with the knowledge and skills they need to provide high-value, cost-conscious care.8,10,57 Our findings suggest that schools using such curricula should introduce the concepts of stewardship and systems thinking early in training, equip students with strategies to help overcome perceived barriers to cost-conscious care, and encourage reflection and discussion about whether the learning environment reinforces what is taught in formal curricula with respect to cost-conscious care.16–18

Although physician role models are important drivers of the informal and hidden curricula experienced by students,26,58 they themselves are subject to the social pressures, norms, and practice patterns of their institution and region.59 In keeping with this, students training in regions with higher health care intensity reported observing fewer cost-conscious role-modeling behaviors than students training in regions with less intense use of health care resources. These students may thus be exposed to (and potentially imprinted by) a culture of medical practice characterized by higher-spending practice patterns. Health care system reform (e.g., value-based reimbursement models, increased cost transparency2) and care models that promote trusting physician–patient relationships60 may make cost-conscious role-modeling behaviors more likely to occur. However, our findings also suggest that medical schools (especially those located in high-health-care-intensity regions) may benefit from additional faculty development related to role modeling cost-conscious care.

Efforts to improve role modeling should start by encouraging faculty to develop an awareness that any action observed by a learner constitutes role modeling27 and can be used deliberately as a teaching tool.61 For example, encounters with patients who request unnecessary diagnostic tests can be treated as valuable opportunities to show students how to engage in shared decision making around the issue of costs.62 Directing learners’ attention toward role-modeled behaviors—either by discussing them before an encounter or reflecting on them after—increases the likelihood that role modeling will be noticed and absorbed.61 Patients are more receptive to discussing costs when they trust their physician,60 so communication and relationship-building skills deserve particular attention and reinforcement. Similarly, faculty can seek cost-effectiveness data in a way that is visible to students, praise them for proposing cost-effective plans of care, and encourage them to include “value” in their case presentations.48,63,64 Medical schools can also strategically expose students to physicians who are known to role model high-value, cost-conscious care. Such efforts could include the creation of training experiences or branch campuses in regions with lower health care intensity.

Regional health care intensity was not associated with reported exposure to potentially wasteful role-modeling behaviors in this study. However, these role-modeling behaviors may be more difficult for students to recognize; for example, students may not realize that testing is excessive or that a referral is unnecessary unless the physician they are observing makes that explicit to them. Thus, potentially wasteful behaviors may have more insidious effects on students, contributing to a hidden curriculum that is more invisible in its presence and impact than formal learning activities.44 Providing opportunities for students to reflect on and evaluate the practice patterns they observe may be one way medical schools can help students recognize and learn from role-modeled behaviors.64,65

The generalizability of our results is supported by the inclusion of private and public medical schools that are geographically distributed across the United States. Furthermore, the characteristics of respondents were similar to those of the total sampled population and U.S. medical students in general, reducing concerns about nonresponse bias. Nevertheless, our study has limitations. First, the 10 participating schools were recruited through the AMA Accelerating Change in Medical Education initiative,29 so the findings reported here may not reflect the attitudes and experiences of all U.S. medical students. Second, our survey may have omitted key attitudes, barriers, or role-modeling behaviors that were not identified in our review of the literature and published surveys of physicians. Third, our classification of role-modeling behaviors as cost-conscious or potentially wasteful, although based on the literature, may not apply in all situations and does not fully capture the complex trade-offs between financial and nonfinancial resources that physicians make in practice.66

Fourth, student responses to the role-modeling items were based on recall and may not accurately or completely reflect their actual experiences. Likewise, students were not asked where they had observed particular role-modeling behaviors (e.g., inpatient vs. outpatient settings) or about the behaviors of residents and fellows, who also serve as role models for students. Fifth, health care intensity may vary within a given HRR, so regional measures of health care intensity may not accurately reflect the health care intensity actually experienced by individual students within that region. Students may also rotate at hospitals outside the primary HRR associated with their school, and health care intensity at those hospitals may differ from that of hospitals within the primary HRR.

Sixth, Medicare-claims-based data, although commonly used, are imperfect measures of health care intensity, and the most recent data available at the time of this study were from 2012. Finally, cross-sectional surveys cannot establish cause-and-effect relationships, so associations should be interpreted with caution.

In conclusion, this study describes the attitudes and experiences of U.S. medical students related to cost-conscious care and demonstrates that students report observing fewer cost-conscious role-modeling behaviors in regions with higher health care intensity. Efforts to enhance physician role modeling in undergraduate medical education may play an important role in preparing the next generation of physicians to address health care costs.

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