Study reports on medical resident knowledge of High Value Care via exam vignette

The IM-ITE is a multiple-choice exam developed by the American College of Physicians (ACP) in collaboration with the Alliance for Academic Internal Medicine (AAIM) to help residents along with their program directors assess their knowledge of internal medicine and identify areas for improvement.

ACP has a High Value Care initiative, including a curriculum for residents co-developed with AAIM, to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices. ACP and AAIM identified 38 of 340 questions in the 2012 IM-ITE to create a High Value Care sub-score.

"While HVC sub-scores correlated strongly with overall IM-ITE performance, we did find some association between medical resident sub-scores and the care intensity of the training hospital," said study co-author Dr. Cynthia Smith, a Senior Physician Educator at ACP. "The HVC sub-score is an imperfect and partial reflection of the residency program care environment. It is a helpful tool but should not be used in isolation to assess resident competence in High Value Care."

The most common associated HVC competency was managing conservatively when appropriate (i.e., including allowing adequate time for clinical improvement, observation and monitoring, or comparison to prior studies rather than additional diagnostic testing).

The study authors used the hospital care intensity (HCI) index calculated by the Dartmouth Atlas group to characterize the intensity of the care environment of each residency program's primary training hospital. The HCI index is a composite measure of hospital days and inpatient physician visits for Medicare recipients in last two years of life.

"Future longitudinal studies are needed to evaluate how well HVC sub-scores approximate actual resident and independent practice, and focus on the development of stronger tools for measuring HVC in practice," said Dr. Smith.

At the end of the 2012 IM-ITE, participants were asked complete a voluntary two-page survey designed by ACP and AAIM that included items about behaviors related to HVC. Residency programs in higher quartiles of HVC sub-scores had a slightly larger proportion of residents who reported avoiding ordering unnecessary tests and treatments and incorporating patients' values into clinical decisions.