Qualitative evaluation of a narrative reflection program to help medical trainees recognize and avoid overuse: “Am I doing what’s right for the patient?”

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Highlights

  • Medical overuse is a contributor to harm and a barrier to high value care but is hard to recognize.

  • Medical residents were invited to reflect on and write up clinical narratives describing overuse.

  • A qualitative evaluation explored impact of reflective writing on participants.

  • Reflective writing may help trainees recognize and avoid medical overuse.

Abstract

Objective

The Do No Harm Project is a novel reflective writing program that encourages medical trainees to reflect on and write up clinical narratives about instances of avoidable medical overuse. Our goal is to describe this program and to explore the effect of the program on those participating.

Methods

Semi-structured interviews were conducted to explore how participating in the project influenced the thinking, attitudes, and behaviors of participating internal medicine residents. Interviews were conducted with 20 out of the 24 participants from the first 15 months of the program.

Results

The following themes emerged from our analysis: 1) learning through reflection (with three sub-themes: empathy for the patient perspective, a critical approach to one’s own clinical practice, and awareness of the problem of overuse); 2) empowerment to discuss instances of overuse and act before it occurs; and 3) perceptions of enhanced evidence-based practice and shared decision-making.

Conclusion

Trainees volunteering to complete a reflective writing exercise perceived improved ability to avoid overuse and improved self-efficacy to change clinical behaviors that do not align with optimal patient care.

Practice implications

Reflective writing may help trainees recognize and avoid medical overuse.

Introduction

Medical overuse – the provision of care where benefits do not outweigh risks – is common [1] and can lead to patient harm [2]. In addition to avoiding underuse of beneficial services, avoidance of overuse is a prerequisite for achieving high value care [3]. However, recognizing overuse at the point-of-care is challenging [4].

In 2011, Weinberger proposed high value care – “the best care for the patient, with the optimal result for the circumstances, delivered at the right price” – as a critical competency for physicians. Yet, the most effective methods for imparting these skills has not been clear [5], [6]. While medical educators are increasingly aware that trainees must assess the appropriateness of medical interventions, existing curricula on teaching high value care are not viewed as adequate [7]. A recent systematic review pointed to important ways educational programs can convey high value care principles to learners. Key among them is establishing a supportive environment that encourages reflective practice and critical examination of clinical decisions and their impact on patient care [8]. Though a growing literature supports the idea that self-reflection is a powerful tool to enhance recognition and understanding of complex issues, we are not aware of a program using self-reflection as a tool to educate trainees about identifying and avoiding medical overuse [9].

To improve the prospective recognition of medical overuse among medical trainees, a novel reflective writing program was developed and implemented in 2012 at the University of Colorado School of Medicine [10], [11]. This paper describes the writing program and explores how participating in the project influenced the thinking, attitudes, and behaviors of internal medicine residents who completed a vignette during its first year. We hypothesized that the program would increase perceived awareness about the problem of overuse and promote self-reflection about how to avoid overuse in the future.

Section snippets

Methods

The Do No Harm Project encourages internal medicine housestaff (post graduate training years 1–3) to write up clinical vignettes describing instances of potentially avoidable tests or treatments that led to harm in patients they cared for previously. Additionally, trainees are asked to consider the many conscious and unconscious drivers of overuse such as fee for service, gaps in knowledge and/or evidence, fear of litigation, local practice culture, and cognitive biases. Rather than reviewing

Results

Fifteen months after the program was initiated, 32 internal medicine residents had volunteered to participate. Of these, 8 did not complete a final draft and were not approached for interviews. Data saturation was achieved after we interviewed 20 (83%) of the 24 residents agreeing to participate in the study. Table 1 presents characteristics of the interviews and 20 study participants. Eight of the 20 participants were female (40%), 3 had published their vignette in a journal, and most

Discussion

Using semi-structured interviews, we explored how, if at all, participating in a novel reflective writing program focused on overuse could influence the thinking, attitudes, and self-perceived behaviors of participating residents. Residents reported that the process of writing up a vignette that focuses on patient-centered aspects of overuse and examines the evidence supporting the case for overuse influenced them in the following ways: promoting critical self-reflection on the topic of

Funding/support

This work was supported by a VA Advanced Fellowship in Health Services Research & Development as well as the Department of Medicine at the University of Colorado. Additionally, Dr. Matlock (K23AG040696), was supported by the National Institute on Aging and the American Federation for Aging Research.

Ethical approval

This study was approved by the IRB at the University of Colorado as an exempt protocol.

Declaration of conflicting interests

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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