Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study

BACKGROUND

Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC.

OBJECTIVE

To explore the relationship between medical student experiences and HVCCC attitudes.

DESIGN

Quantitative and qualitative analysis of a multi-institutional survey.

PARTICIPANTS

Medical students from nine US medical schools.

APPROACH

A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis.

KEY RESULTS

A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes.

CONCLUSION

Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

A novel virtual course to teach medical students high-value decision-making

BACKGROUND

Although a clinician's ability to employ high-value decision-making is influenced by training, many undergraduate medical education programmes lack a formal curriculum in high-value, cost-conscious care. We present a curriculum developed through a cross-institutional collaboration that was used to teach students at two institutions about this topic and can serve as a framework for other institutions to develop similar curricula.

APPROACH

The faculty from the University of Virginia and the Johns Hopkins University School of Medicine created a 2-week-long online course to teach medical students the fundamentals of high-value care. The course consisted of learning modules, clinical cases, textbook studies, journal clubs and a competitive 'Shark Tank' final project where students proposed a realistic intervention to promote high-value clinical care.

EVALUATION

Over two-thirds of students rated the course's quality as excellent or very good. Most found the online modules (92%), assigned textbook readings (89%) and 'Shark Tank' competition (83%) useful. To evaluate the student's ability to apply the concepts learned during the course in clinical contexts, we developed a scoring rubric based on the New World Kirkpatrick Model to evaluate students' proposals. Groups chosen as finalists (as determined by faculty judges) were more likely to be fourth-year students (56%), achieved higher overall scores (p = 0.03), better incorporated cost impact at several levels (patient, hospital and national) (p = 0.001) and discussed both positive and negative impacts on patient safety (p = 0.04).

IMPLICATIONS

This course provides a framework for medical schools to use in their teaching of high-value care. Cross-institutional collaboration and online content overcame local barriers such as contextual factors and lack of faculty expertise, allowed for greater flexibility, and enabled focused curricular time to be spent on a capstone project competition. Prior clinical experience amongst medical students may be an enabling factor in promoting application of learning related to high-value care.

Teaching the science of uncertainty

As we increasingly acknowledge the ubiquitous nature of uncertainty in clinical practice (Meyer AN, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Counsel 2021;104:2606-15; Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31:828-38) and strive to better define this entity (Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2020; Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103-15), as educators we should also design, implement, and evaluate curricula addressing clinical uncertainty. Although frequently encountered, uncertainty is often implicitly referred to rather than explicitly discussed (Gärtner J, Berberat PO, Kadmon M, Harendza S. Implicit expression of uncertainty - suggestion of an empirically derived framework. BMC Med Educ 2020;20:83). Increasing explicit discussion of - and comfort with -uncertainty has the potential to improve diagnostic reasoning and accuracy and improve patient care (Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. Engaging. Uncertainty when teaching clinical reasoning. Scholar;1:364-71). Discussion of both diagnostic and prognostic uncertainty with patients is central to shared decision-making in many contexts as well, (Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med 2019;34:2586-91) from the outpatient setting to the inpatient setting, and from undergraduate medical education (UME) trainees to graduate medical education (GME) trainees. In this article, we will explore the current status of how the science of uncertainty is taught from the UME curriculum to the GME curriculum, and describe strategies how uncertainty can be explicitly discussed for all levels of trainees.

C. elegans slit acts in midline, dorsal-ventral, and anterior-posterior guidance via the SAX-3/Robo receptor

Robo receptors interact with ligands of the Slit family. The nematode C. elegans has one Robo receptor (SAX-3) and one Slit protein (SLT-1), which direct ventral axon guidance and guidance at the midline. In larvae, slt-1 expression in dorsal muscles repels axons to promote ventral guidance. SLT-1 acts through the SAX-3 receptor, in parallel with the ventral attractant UNC-6 (Netrin). Removing both UNC-6 and SLT-1 eliminates all ventral guidance information for some axons, revealing an underlying longitudinal guidance pathway. In the embryo, slt-1 is expressed at high levels in anterior epidermis. Embryonic expression of SLT-1 provides anterior-posterior guidance information to migrating CAN neurons. Surprisingly, slt-1 mutants do not exhibit the nerve ring and epithelial defects of sax-3 mutants, suggesting that SAX-3 has both Slit-dependent and Slit-independent functions in development.

Myosin VI is required for asymmetric segregation of cellular components during C. elegans spermatogenesis

BACKGROUND

The asymmetric division of cells and unequal allocation of cell contents is essential for correct development. This process of active segregation is poorly understood but in many instances has been shown to depend on the cytoskeleton. Motor proteins moving along actin filaments and microtubules are logical candidates to provide the motive force for asymmetric sorting of cell contents. The role of myosins in such processes has been suggested, but few examples of their involvement are known.

RESULTS

Analysis of a Caenorhabditis elegans class VI myosin deletion mutant reveals a role for this motor protein in the segregation of cell components during spermatogenesis. Mutant spermatocytes cannot efficiently deliver mitochondria and endoplasmic reticulum/Golgi-derived fibrous-body membranous organelle complexes to budding spermatids, and fail to remove actin filaments and microtubules from the spermatids. The segregation defects are not due to a global sorting failure as nuclear inheritance is unaffected.

CONCLUSIONS

C. elegans myosin VI has an important role in the unequal partitioning of both organelles and cytoskeletal components, a novel role for this class of motor protein.

Expression of multiple UNC-13 proteins in the Caenorhabditis elegans nervous system

The Caenorhabditis elegans UNC-13 protein and its mammalian homologues are important for normal neurotransmitter release. We have identified a set of transcripts from the unc-13 locus in C. elegans resulting from alternative splicing and apparent alternative promoters. These transcripts encode proteins that are identical in their C-terminal regions but that vary in their N-terminal regions. The most abundant protein form is localized to most or all synapses. We have analyzed the sequence alterations, immunostaining patterns, and behavioral phenotypes of 31 independent unc-13 alleles. Many of these mutations are transcript-specific; their phenotypes suggest that the different UNC-13 forms have different cellular functions. We have also isolated a deletion allele that is predicted to disrupt all UNC-13 protein products; animals homozygous for this null allele are able to complete embryogenesis and hatch, but they die as paralyzed first-stage larvae. Transgenic expression of the entire gene rescues the behavior of mutants fully; transgenic overexpression of one of the transcripts can partially compensate for the genetic loss of another. This finding suggests some degree of functional overlap of the different protein products.

Prolyl 4-hydroxylase is required for viability and morphogenesis in Caenorhabditis elegans

The genome of Caenorhabditis elegans possesses two genes, dpy-18 and phy-2, that encode alpha subunits of the enzyme prolyl 4-hydroxylase. We have generated deletions within each gene to eliminate prolyl 4-hydroxylase activity from the animal. The dpy-18 mutant has an aberrant body morphology, consistent with a role of prolyl 4-hydroxylase in formation of the body cuticle. The phy-2 mutant is phenotypically wild type. However, the dpy-18; phy-2 double mutant is not viable, suggesting an essential role for prolyl 4-hydroxylase that is normally accomplished by either dpy-18 or phy-2. The effects of the double mutation were mimicked by small-molecule inhibitors of prolyl 4-hydroxylase, validating the genetic results and suggesting that C. elegans can serve as a model system for the discovery of new inhibitors.

NANOS-3 and FBF proteins physically interact to control the sperm-oocyte switch in Caenorhabditis elegans

BACKGROUND

The Caenorhabditis elegans FBF protein and its Drosophila relative, Pumilio, define a large family of eukaryotic RNA-binding proteins. By binding regulatory elements in the 3' untranslated regions (UTRs) of their cognate RNAs, FBF and Pumilio have key post-transcriptional roles in early developmental decisions. In C. elegans, FBF is required for repression of fem-3 mRNA to achieve the hermaphrodite switch from spermatogenesis to oogenesis.

RESULTS

We report here that FBF and NANOS-3 (NOS-3), one of three C. elegans Nanos homologs, interact with each other in both yeast two-hybrid and in vitro assays. We have delineated the portions of each protein required for this interaction. Worms lacking nanos function were derived either by RNA-mediated interference (nos-1 and nos-2) or by use of a deletion mutant (nos-3). The roles of the three nos genes overlap during germ-line development. In certain nos-deficient animals, the hermaphrodite sperm-oocyte switch was defective, leading to the production of excess sperm and no oocytes. In other nos-deficient animals, the entire germ line died during larval development. This germ-line death did not require CED-3, a protease required for apoptosis.

CONCLUSIONS

The data suggest that NOS-3 participates in the sperm-oocyte switch through its physical interaction with FBF, forming a regulatory complex that controls fem-3 mRNA. NOS-1 and NOS-2 also function in the switch, but do not interact directly with FBF. The three C. elegans nanos genes, like Drosophila nanos, are also critical for germ-line survival. We propose that this may have been the primitive function of nanos genes.

Meiotic recombination in C. elegans initiates by a conserved mechanism and is dispensable for homologous chromosome synapsis

Chromosome segregation at meiosis I depends on pairing and crossing-over between homologs. In most eukaryotes, pairing culminates with formation of the proteinaceous synaptonemal complex (SC). In budding yeast, recombination initiates through double-strand DNA breaks (DSBs) and is thought to be essential for SC formation. Here, we examine whether this mechanism for initiating meiotic recombination is conserved, and we test the dependence of homologous chromosome synapsis on recombination in C. elegans. We find that a homolog of the yeast DSB-generating enzyme, Spo11p, is required for meiotic exchange in this metazoan, and that radiation-induced breaks partially alleviate this dependence. Thus, initiation of recombination by DSBs is apparently conserved. However, homologous synapsis is independent of recombination in the nematode, since it occurs normally in a C. elegans spo-11 null mutant.