Pediatric Residents' Experiences With High-Value Care at an Academic Children's Hospital.

Abstract

The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described. To explore pediatric residents' experiences with HVC and its facilitators and barriers. We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached. Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants. Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.