Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis

J Gen Intern Med. 2015 Oct;30(10):1491-6. doi: 10.1007/s11606-015-3324-4.


Background: Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care.

Objective: To examine medical students' perceptions of healthcare delivery as it relates to cost consciousness

Design: Retrospective qualitative analysis of medical student narratives

Participants: Third-year medical students during their inpatient internal medicine clerkship

Main measures: Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students' awareness and perceptions regarding the practice of cost-conscious care within our medical center.

Key results: Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.)

Conclusions: Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.

Keywords: Healthcare costs; Medical education—qualitative analysis; Medical education—systems-based practice.

MeSH terms

  • Clinical Clerkship / methods
  • Clinical Clerkship / standards*
  • Female
  • Health Care Costs / standards*
  • Humans
  • Internal Medicine / methods
  • Internal Medicine / standards*
  • Male
  • Perception*
  • Retrospective Studies
  • Students, Medical*
  • Surveys and Questionnaires