High-Value, Cost-Conscious Care Attitudes in the Graduate Medical Education Learning Environment: Various Stakeholder Attitudes That Residents Misjudge.

BACKGROUND: Training residents in delivering high-value, cost-conscious care (HVCCC) is crucial for a sustainable healthcare. A supportive learning environment is key. Yet, stakeholders' attitudes toward HVCCC in residents' learning environment are unknown. OBJECTIVE: We aimed to measure stakeholders' HVCCC attitudes in residents' learning environment, compare these with resident perceptions of their attitudes, and identify factors associated with attitudinal differences among each stakeholder group. DESIGN: We conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018. PARTICIPANTS: Participants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals. MAIN MEASURES: Respondents completed the Maastricht HVCCC Attitude Questionnaire (MHAQ), containing three subscales: (1) high-value care, (2) cost incorporation, (3) perceived drawbacks. Additionally, resident respondents estimated the HVCCC attitudes of other stakeholders, and answered questions on job demands and resources. Univariate and multivariate analyses were used to analyze data. KEY RESULTS: Attitudes differed on all subscales: faculty and administrators reported more positive HVCCC attitudes than residents (p ≤ 0.05), while the attitudes of patients were less positive (p ≤ 0.05). Residents underestimated faculty's (p < 0.001) and overestimated patients' HVCCC attitudes (p < 0.001). Increasing age was, among residents and faculty, associated with more positive attitudes toward HVCCC (p ≤ 0.05). Lower perceived health quality was associated with less positive attitudes among patients (p < 0.001). The more autonomy residents perceived, the more positive their HVCCC attitude (p ≤ 0.05). CONCLUSIONS: Attitudes toward HVCCC vary among stakeholders in the residency learning environment, and residents misjudge the attitudes of both faculty and patients. Faculty and administrators might improve their support to residents by more explicitly sharing their thoughts and knowledge on HVCCC and granting residents autonomy in clinical practice.

Residents' identification of learning moments and subsequent reflection: impact of peers, supervisors, and patients.

BACKGROUND: The clinical workplace offers residents many opportunities for learning. Reflection on workplace experiences drives learning and development because experiences potentially make residents reconsider existing knowledge, action repertoires and beliefs. As reflective learning in the workplace cannot be taken for granted, we aimed to gain a better insight into the process of why residents identify experiences as learning moments, and how residents reflect on these moments. METHODS: This study draws on semi-structured interviews with 33 medical residents. Interviews explored how residents identified learning moments and how they reflected on such moments, both in-action and on-action. Aiming for extensive explanations on the process of reflection, open-ended questions were used that built on and deepened residents' answers. After interviews were transcribed verbatim, a within-case and cross-case analysis was conducted to build a general pattern of explanation. RESULTS: The data analysis yielded understanding of the crucial role of the social context. Interactions with peers, supervisors, and patients drive reflection, because residents want to measure up to their peers, meet supervisors' standards, and offer the best patient care. Conversely, quality and depth of reflection sometimes suffer, because residents prioritize patient care over learning. This urges them to seek immediate solutions or ask their peers or supervisor for advice, rather than reflectively deal with a learning moment themselves. Peer discussions potentially enhance deep reflection, while own supervisor involvement sometimes feels unsafe. DISCUSSION: Our results adds to our understanding of the social-constructivist nature of reflection. We suggest that feelings of self-preservation during interactions with peers and supervisors in a highly demanding work environment shape reflection. Support from peers or supervisors helps residents to instantly deal with learning moments more easily, but it also makes them more dependent on others for learning. Since residents' devotion to patient care obscures the reflection process, residents need more dedicated time to reflect. Moreover, to elaborate deeply on learning moments, a supportive and safe learning climate with peers and supervisors is recommended.

A new instrument to measure high value, cost-conscious care attitudes among healthcare stakeholders: development of the MHAQ.

BACKGROUND: Residents have to learn to provide high value, cost-conscious care (HVCCC) to counter the trend of excessive healthcare costs. Their learning is impacted by individuals from different stakeholder groups within the workplace environment. These individuals' attitudes toward HVCCC may influence how and what residents learn. This study was carried out to develop an instrument to reliably measure HVCCC attitudes among residents, staff physicians, administrators, and patients. The instrument can be used to assess the residency-training environment. METHOD: The Maastricht HVCCC Attitude Questionnaire (MHAQ) was developed in four phases. First, we conducted exploratory factor analyses using original data from a previously published survey. Next, we added nine items to strengthen subscales and tested the new questionnaire among the four stakeholder groups. We used exploratory factor analysis and Cronbach's alphas to define subscales, after which the final version of the MHAQ was constructed. Finally, we used generalizability theory to determine the number of respondents (residents or staff physicians) needed to reliably measure a specialty attitude score. RESULTS: Initial factor analysis identified three subscales. Thereafter, 301 residents, 297 staff physicians, 53 administrators and 792 patients completed the new questionnaire between June 2017 and July 2018. The best fitting subscale composition was a three-factor model. Subscales were defined as high-value care, cost incorporation, and perceived drawbacks. Cronbach's alphas were between 0.61 and 0.82 for all stakeholders on all subscales. Sufficient reliability for assessing national specialty attitude (G-coefficient > 0.6) could be achieved from 14 respondents. CONCLUSIONS: The MHAQ reliably measures individual attitudes toward HVCCC in different stakeholders in health care contexts. It addresses key dimensions of HVCCC, providing content validity evidence. The MHAQ can be used to identify frontrunners of HVCCC, pinpoint aspects of residency training that need improvement, and benchmark and compare across specialties, hospitals and regions.