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U.S. Internal Medicine Residents’ Knowledge and Practice of High-Value Care: A National Survey

Ryskina, Kira L. MD; Smith, Cynthia D. MD; Weissman, Arlene PhD; Post, Jason MD; Dine, C. Jessica MD; Bollmann, KeriLyn MD; Korenstein, Deborah MD

doi: 10.1097/ACM.0000000000000791
Research Reports

Purpose To determine U.S. internal medicine (IM) residents’ knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments.

Method The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age–sex–race–illness standardized measure of hospital days and inpatient physician visits by Medicare recipients).

Results Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they “share estimated costs of tests and treatments with patients”; 15,549 of 17,626 (88.2%) agreed that they “incorporate patients’ values and concerns into clinical decisions.” Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital’s care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors.

Conclusions U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents’ competency in providing value-based care.

Supplemental Digital Content is available in the text.

K.L. Ryskina is general internal medicine fellow, Division of General Internal Medicine, and fellow, Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

C.D. Smith is director of clinical programs development and senior physician educator, American College of Physicians, Philadelphia, Pennsylvania.

A. Weissman is research center director, American College of Physicians, Philadelphia, Pennsylvania.

J. Post is assistant professor, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

C.J. Dine is assistant professor, Division of Pulmonary and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

K. Bollmann is assistant professor, Department of Medicine, Banner Good Samaritan Medical Center, Phoenix, Arizona.

D. Korenstein is clinical member, Memorial Hospital at Memorial Sloan Kettering Cancer Center, New York, New York.

Funding/Support: Kira L. Ryskina is supported by the Ruth L. Kirschstein National Research Service Award (T32-HP10026). This study received no external funding.

Other disclosures: None reported.

Ethical approval: The Mayo Clinic institutional review board reviewed this study and deemed it exempt.

Previous presentations: These data were presented in preliminary form during the Lipkin Finalist Abstract Session at the Society of General Internal Medicine Annual Meeting in San Diego, California, on April 25, 2014.

Supplemental digital content for this article is available at

Correspondence should be addressed to Kira L. Ryskina, Blockley Hall 13-30B4, 423 Guardian Dr., Philadelphia, PA 19104; telephone: (215) 746-4315; e-mail:

© 2015 by the Association of American Medical Colleges