A multimodal high-value curriculum affects drivers of utilization and performance on the high-value care component of the internal medicine in-training exam

Background: Teaching the practice of high-value care (HVC) is an increasingly important function of graduate medical education but best practices and long-term outcomes remain unknown. Objective: Whether a multimodal curriculum designed to address specific drivers of low-value care would affect resident attitudes, skills, and performance of HVC as tested by the Internal Medicine In-Training Exam (ITE). Methods: In 2012, we performed a baseline needs assessment among internal medicine residents at a community program regarding drivers of healthcare utilization. We then created a multimodal curriculum with online interactive worksheets, lectures, and faculty buy-in to target specific skills, knowledge, and culture deficiencies. Perceived drivers of care and performance on the Internal Medicine ITE were assessed yearly through 2016. Results: Fourteen of 27 (52%) residents completed the initial needs assessment while the curriculum was eventually seen by at least 24 of 27 (89%). The ITE was taken by every resident every year. Long-term, 3-year follow-up demonstrated persistent improvement in many drivers of utilization (patient requests, reliance on subspecialists, defensive medicine, and academic curiosity) and improvement with sustained high performance on the high-value component of the ITE. Conclusion: A multimodal curriculum targeting specific drivers of low-value care can change culture and lead to sustained improvement in the practice of HVC.