Overuse is rampant in medicine. Evidence suggests that up to 30% of the health care provided in the United States is unnecessary. The roots of overuse in medical practice originate in medical education. Studies have shown that residents trained in clinical learning environments with more intense use of health care resources continue to follow more resource-intensive practice patterns in the future, as compared with residents trained in environments with less intense resource use.1,2 A “hidden curriculum” pervasive in the academic environment encourages students and residents to search for all possible diagnoses through extensive (and often unnecessary) diagnostic workups, thereby demonstrating their knowledge, thoroughness, and curiosity.3 Often, restraint is discouraged, and students learn that good medicine is exhaustive in investigation and unrelenting in treatment, even in the face of potential harm and no clinical benefit to patients.4
Choosing Wisely is a physician-led movement that aims to curb medical overuse in the United States, Canada, and around the globe.5 Participating national specialty societies have developed specialty-specific lists of recommendations targeting unnecessary care, but none of these lists have targeted medical education or medical students. Choosing Wisely Canada (CWC)—in partnership with the Canadian Federation of Medical Students (CFMS) and the Fédération médicale étudiante du Québec (FMEQ), which together represent all medical students in Canada—therefore convened a student-led taskforce in May 2015 to develop a list of recommendations for medical students modeled after the specialty lists.
The CWC student-led taskforce members included three University of Toronto medical students (A.L., E.L., W.S.) and three faculty members (K.B., W.L., B.W.) with expertise in health care quality, health policy, medical education, and resource stewardship. We undertook a literature review to identify processes that specialty organizations had used to create their lists, and we supplemented this with the faculty members’ knowledge of how more than 30 Canadian specialty organizations had generated their lists (as coordinated by CWC). The University of Toronto research ethics board deemed this process exempt from full review.
We chose not to focus the list of recommendations for students on specific clinical diseases as is done by the Choosing Wisely specialty lists. Rather, we chose to target student behaviors with respect to resource stewardship practices. We selected this approach because behaviors learned in medical training play crucial roles in shaping future practice patterns1,2 and because students are too early in their careers to focus on a small number of diseases. We deliberately worded the candidate recommendations as “do not” statements, similar to the “don’t” format of many Choosing Wisely recommendations.
We developed four criteria for candidate recommendations, which followed the guiding principles used by specialty societies. Specifically, the issue should (1) arise frequently in medical school training, (2) have relevance to medical students, (3) play a role in shaping future behaviors, and (4) be one that medical students could feasibly address during their training.
Figure 1 provides an overview of our list development process. We reviewed the medical education and resource stewardship literature and, on the basis of that review, developed a preliminary list of 12 recommendations.3,4,6 This preliminary list was reviewed in June 2015 by the CFMS and FMEQ executive committees, as well as four medical students and residents who have been engaged in resource stewardship and medical education initiatives. On the basis of their feedback, we refined the preliminary list to 10 candidate recommendations to reduce redundancy.
Subsequently, we conducted a national consultation of Canadian medical students through an online questionnaire (FluidSurveys, Ottawa, Ontario, Canada). We distributed the questionnaire in English and French in July 2015; invitations to participate, with links to the survey, were sent out via the CFMS and FMEQ e-mail listserves, medical school listserves, and social media (e.g., Facebook, Twitter). Respondents were offered the opportunity to enter a draw to win an Apple Watch or one of ten $10 gift cards as an incentive to complete the survey. We inferred that students who submitted their completed questionnaires provided implied consent for their data to be included in our consultation process.
The student questionnaire (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A380) included background information on the Choosing Wisely campaign and described the purpose of the list. Respondents were asked to rate each of the 10 candidate recommendations as “definitely consider,” “maybe consider,” or “definitely do not consider.” Respondents also had the option of suggesting additional recommendations and providing general comments. This student feedback was used to rank the 10 items according to the percentages of “definitely consider” responses. This ranked list informed finalization of the recommendations.
Of the estimated 9,000 students across Canada targeted to receive the questionnaire, 1,878 students from all 17 of Canada’s medical schools provided input. The majority responded in English (n = 1,395; 74%), were female (n = 1,122; 60%), and were not previously aware of CWC (n = 1,144; 61%). Respondents were in their first (n = 69; 4%), second (n = 679; 36%), third (n = 660; 35%), or fourth (n = 388; 21%) year of medical school; another 82 students (4%) responded as “other” (e.g., MD–PhD programs, research year, or prefer not to disclose).
Table 1 summarizes the results of the national medical student consultation, identifying the 6 recommendations selected for inclusion in the final list as well as the 4 that were not selected. From the 10 candidate recommendations, we removed recommendation 8 because it was scored low by respondents, and we eliminated 3 recommendations because they were redundant with higher-ranked recommendations. We decided to include recommendation 6, despite a lack of consensus among respondents, because both the literature and students’ comments on the questionnaire noted students’ desire to please supervisors, a concept captured by this recommendation but not the others.
Students’ comments also included requests for illustrative examples of the recommendations. As such, we developed clinical vignettes for each recommendation in the final CWC list of “Six Things Medical Students and Trainees Should Question” (Table 2).
The CFMS and FMEQ executive committees endorsed the final list in October 2015. It was publicly released on the CWC Web site in November 2015 (see http://www.choosingwiselycanada.org/recommendations/medical-students-and-trainees/).
Medical students recognize the need to consider resource stewardship during training. Nearly 2,000 medical students in Canada engaged in the process of developing a set of Choosing Wisely recommendations that equip students with tools to ask questions and initiate conversations with attending physicians and fellow trainees regarding unnecessary care. Beyond underscoring the need for formal training on the costs and value of care, the recommendations included in this list highlight the influence of the culture of medical training on student behaviors. They are consistent with situated learning theories, which indicate that medical student learning is socially constructed and a product of the activity, context, and culture in which it is developed and used.7,8 Medical students may establish long-lasting overuse practices through their lived clinical experiences and their exposure to the cultural norms embedded within the learning environment.1,2
Specifically, this list for medical education includes recommendations highlighting behaviors to avoid (e.g., “Don’t suggest ordering the most invasive test before considering other less invasive options”) as well as behaviors related to aspects of the medical training culture that may promote overuse, such as the hierarchical nature of clinical supervision (e.g., “Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe may be ordered inappropriately”). These six “don’t” statements and the associated illustrative clinical vignettes (Table 2) provide a basis for students to reflect on cultural norms in medical education and the influence of the norms on their behaviors and practice patterns.3,4
We hope that this list of recommendations will have an impact on faculty as well, because faculty strongly influence the cultural and behavioral norms in medical education that affect learning about resource stewardship. The recommendations also highlight where physicians’ own supervision practices or behaviors might negatively influence student behaviors and promote overuse. Teaching resource stewardship effectively in the classroom and at the bedside requires robust faculty development, however.9 To address this need, existing faculty development efforts in quality improvement, such as the Association for American Medical Colleges’ Teaching for Quality program (https://www.aamc.org/initiatives/cei/te4q/), could be expanded to include content on teaching about resource stewardship. The high-value care curriculum in internal medicine9—codeveloped by the American College of Physicians and the Alliance for Academic Internal Medicine9—could be adapted to other specialties.
Further, medical schools need to ensure that their learning environment fosters clinical experiences for medical students that encourage appropriate use of tests and treatments. One concrete way to achieve this could be through creating programs like the Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review (CLER) program, which uses site visits to increase the educational emphasis on patient safety and quality of care in graduate medical education.10 The six areas of focus within CLER—Patient Safety; Quality Improvement; Transitions in Care; Supervision; Duty Hours, Oversight, Fatigue Management and Mitigation; and Professionalism—could be adapted to more explicitly highlight issues of cost and value to ensure that learning environments support the teaching and learning of resource stewardship principles. The recommendations in the CWC list of “Six Things Medical Students and Trainees Should Question” could be used to foster such innovations and draw attention to the need to develop, integrate, and evaluate resource stewardship training in medical schools. One critical next step would be to seek the official endorsement of organizations such as the Association of American Medical Colleges and the Association of Faculties of Medicine of Canada. These organizations are highly respected by members of the medical education community; their endorsement would go a long way toward garnering support for such changes and would be a future part of the list dissemination plan.
We realize that some of the recommen dations in this list may be challenging for students to follow because students understandably may be reluctant to question an authority figure such as a faculty member. To help lend legitimacy to the student voice, CWC launched STARS (Students and Trainees Advocating for Resource Stewardship) in November 2015. Over 100 students from across Canada applied, and 2 from each of the 17 Canadian medical schools were invited to undertake leadership training and launch grassroots student movements at their respective schools to enact change and raise the profile of resource stewardship in medical education. The goal of STARS is to leverage the success of Choosing Wisely among practicing physicians to raise awareness among students, faculty, and educational leaders regarding the roles they can play to create learning environments that support students’ learning effective stewardship of health care resources at the outset of their professional careers.
There were limitations to the process used to develop this list. In contrast to the Choosing Wisely lists developed by national specialty societies, the recommendations included in this list were not supported by a definitive literature. Also, we did not use a formal consensus-building process because of time and resource constraints, but we used an approach similar to other Choosing Wisely list generation processes. We believe that the national consultation involving nearly 2,000 medical students, as well as our engagement with students and residents with resource stewardship expertise, provided sufficient validation. Although the consultation engaged Canadian medical students, the list is equally relevant to medical students in the United States because medical education in the two countries is structured in the same fashion and shares an accreditation process.
We hope that, in addition to raising awareness about the need to emphasize resource stewardship in medical education, this list will engage medical students and faculty to actively participate in Choosing Wisely campaigns and to work together to transform how we train future physicians to provide high-value, patient-centered care.
Acknowledgments: The authors wish to acknowledge the executive committees of the Canadian Federation of Medical Students and Fédération médicale étudiante du Québec for their involvement in the list development process.
1. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med. 2014;174:16401648.
2. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312:23852393.
3. Rosenbaum L, Lamas D. Cents and sensitivity—teaching physicians to think about costs. N Engl J Med. 2012;367:99101.
4. Detsky AS, Verma AA. A new model for medical education: Celebrating restraint. JAMA. 2012;308:13291330.
5. Moriates C, Soni K, Lai A, Ranji S. The value in the evidence: Teaching residents to “choose wisely.” JAMA Intern Med. 2013;173:308310.
6. Levy AE, Shah NT, Moriates C, Arora VM. Fostering value in clinical practice among future physicians: Time to consider COST. Acad Med. 2014;89:1440.
7. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79:186194.
8. Mann KV. Theoretical perspectives in medical education: Past experience and future possibilities. Med Educ. 2011;45:6068.
9. Smith CD, Levinson WS; Internal Medicine HVC Advisory Board. A commitment to high-value care education from the internal medicine community. Ann Intern Med. 2015;162:639640.
10. Nasca TJ, Weiss KB, Bagian JP. Improving clinical learning environments for tomorrow’s physicians. N Engl J Med. 2014;370:991993.