SOAP to SOAP-V: A New Paradigm for Teaching Students High Value Care

Abstract

Perspectives Viewpoints•Medical students are well positioned to bring value discussions into patient care activities.•Students at 3 medical schools used the SOAP-V framework during team presentations to apply high value care in their medical decision making.•The intervention group reported higher self-efficacy toward addressing the economic health care crisis, initiating team discussions on unnecessary tests or treatments, and considering potential costs to patient and system; these changes were not present in the control group. •Medical students are well positioned to bring value discussions into patient care activities.•Students at 3 medical schools used the SOAP-V framework during team presentations to apply high value care in their medical decision making.•The intervention group reported higher self-efficacy toward addressing the economic health care crisis, initiating team discussions on unnecessary tests or treatments, and considering potential costs to patient and system; these changes were not present in the control group. 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Starr S.R. et al.Role modeling and regional health care intensity: U.S. medical student attitudes toward and experiences with cost-conscious care.Acad Med. 2017; 92: 694-702Crossref PubMed Scopus (29) Google Scholar and residents report that only 54% of their faculty consistently role model cost-conscious care.13Patel M.S. Reed D.A. Smith C. Arora V.M. Role-modeling cost-conscious care–a national evaluation of perceptions of faculty at teaching hospitals in the United States.J Gen Intern Med. 2015; 30: 1294-1298Crossref PubMed Scopus (26) Google Scholar Several medical schools have developed HVC curricula focused on delivering content knowledge.14Muntz M. Thomas J. Quirk K. Thapa B. Frank M. Clerkship students as high-value care officers increased awareness and practice of cost-conscious care. Abstracts from the Proceedings of the 2014 Annual Meeting of the Clerkship Directors of Internal Medicine (CDIM).Teach Learn Med. 2015; 27: 349-350Google Scholar, 15Dillon J.E. Slanetz P.J. Teaching evidence-based imaging in the radiology clerkship using the ACR appropriateness criteria.Acad Radiol. 2010; 17: 912-916Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar We created a point-of-care tool, SOAP-V, to empower students to integrate HVC into their medical decision making during oral presentations and note writing. The SOAP-V framework modifies the traditional SOAP format (Subjective–Objective–Assessment–Plan) to include value (V). The framework prompts students to consider 3 aspects of HVC: evidence of value, patient preferences, and consideration of cost (Figure). We conceptualized SOAP-V during the Millennium Conference 2013 on Teaching High Value Care16Huang G.C. Tibbles C.D. Newman L.R. Schwartzstein R.M. Consensus of the millennium conference on teaching high value care.Teach Learn Med. 2016; 28: 97-104Crossref PubMed Scopus (12) Google Scholar and subsequently refined the tool. Details of the development of SOAP-V have been described previously.17Moser E.M. Huang G.C. Packer C.D. et al.SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve.J Hosp Med. 2015; 11: 217-220Crossref PubMed Scopus (13) Google Scholar SOAP-V serves as a cognitive forcing tool18Croskerry P. Cognitive forcing strategies in clinical decisionmaking.Ann Emerg Med. 2003; 41: 110-120Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar embedded into the normal workflow to remind team members to consider HVC. We taught students about SOAP-V and encouraged them to use this framework to bring up value concepts with attending physicians and residents during medical decision making. We envisioned SOAP-V as a tool to provide students with authentic, repeated practice opportunities to transfer HVC principles into their medical decision making and team discussions, optimize student learning,19Knowles M. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development.6th ed. Elsevier, Burlington, MA2005Google Scholar, 20Hodges B. Medical education and the maintenance of incompetence.Med Teach. 2006; 28: 690-696Crossref PubMed Scopus (89) Google Scholar and increase student change agency21Bandura A. Self-efficacy: toward a unifying theory of behavioral change.Psychol Rev. 1977; 84: 191-215Crossref PubMed Scopus (29294) Google Scholar in practicing HVC. Using Bandura's definition of self-efficacy, namely the confidence in the ability to exert control over one's own motivation, behavior, and social environment,18Croskerry P. Cognitive forcing strategies in clinical decisionmaking.Ann Emerg Med. 2003; 41: 110-120Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar this study examines the impact of SOAP-V on student self-efficacy in applying HVC principles. We launched a 1-year, institutional review board–approved study for academic year 2014-2015 to implement SOAP-V at Pennsylvania State University College of Medicine (PSUCOM), Harvard Medical School (HMS), and Case Western Reserve University School of Medicine (CWRU). Participants were third-year medical students during their internal medicine clerkships. This study received exempt status and approval from the institutional review boards of Penn State College of Medicine (March 20, 2014, STUDY00000265), Harvard Medical School (April 3, 2014, IRB14-0708), Beth Israel Deaconess Medical Center (March 14, 2014, 2014P-000079), Louis Stokes Cleveland Veterans Administration Medical Center (March 28, 2014, CY14-036), and Case Western Reserve University (May 29, 2014, IRB-2014-830). We conducted a nonrandomized controlled trial, with half of the third-year students at each institution in the control arm and half in the intervention arm. Before the clerkship both control and intervention students attended a 1-hour lecture on general principles of HVC. Students in the intervention group received an additional 1-hour SOAP-V training session, which included background on overuse and pressures faced by students on rounds to order unnecessary tests; introduction to the SOAP-V framework; a video of a student using SOAP-V on rounds; and role-play opportunities using SOAP-V in their presentations. They received a pocket card (Figure), which referenced Healthcarebluebook.com, a website that displays health care costs by US geographic region.22Healthcare Bluebook. CareOperative LLC.https://healthcarebluebook.comGoogle Scholar We asked students to use the SOAP-V framework during inpatient rounds and informed faculty and residents that students might incorporate elements of HVC into their discussions. We did not provide SOAP-V instruction to faculty, residents, or control-arm students. To evaluate the impact of SOAP-V, we surveyed all students on their self-efficacy in applying HVC, queried students in the intervention group about the types of value conversations held on rounds, and conducted 3 end-of-year student focus groups.Students provided the last 4 digits of their cell phone numbers as nonidentifying codes for linking pre- and postintervention data. We conducted focus groups at the end of the academic year at PSUCOM and HMS on the value of SOAP-V, using volunteers from the intervention group, facilitated by faculty not involved in clerkship evaluation. Audio recordings were collected and transcribed without identifying data. We tabulated student results and dichotomized responses on 5-point scales as “strongly agree” or “agree” versus all other responses. We analyzed student survey results using McNemar's test to compare results by individuals. We compared pre- with postintervention surveys and pre- with end-of-year surveys, by intervention and control groups. We tabulated the value self-audit results. All inferential analyses were conducted using Stata 13 (StataCorp, College Station, Tex). We performed a thematic analysis of the focus group data. Two investigators (SBF, SAG) independently reviewed the transcripts and came to consensus on themes. We performed member checks by sending summaries to participants to ensure that their opinions were accurately represented. A total of 265 medical students participated (PSUCOM, 137; CWRU, 80; HMS, 48) (Appendix A, available online). The cohorts were similar across study sites except for HMS, where a higher proportion of students had received training in cost-consciousness in medical school. The overall student response rates to the survey were 100% before intervention (paper-based), 51% after intervention (electronic), and 51% at the end of the year (electronic). The response rates at each site did not vary significantly in postintervention measures (CWRU, 45%; HMS, 65%; PSUCOM, 49%; P = .086) but did by end of year (CWRU, 18%; HMS, 42%; PSUCOM, 74%; P < .001). In the intervention group, paired analyses showed statistically significant increases from before to after intervention in the following self-efficacy statements: “I have the power to address the economic health care crisis” (P = .005), “I would be comfortable initiating a discussion about unnecessary tests or treatments with my team” (P = .035), “In my clinical decisions, I consider the potential costs to the patient” (P = .003), and “In my clinical decisions, I consider the potential costs to the health care system” (P < .001) (Table). By year end, positive responses toward the statement, “In my clinical decisions, I consider the potential costs to the health care system” (P = .013) persisted, and “I have the resources/means to make cost-conscious decisions” (P = .020) increased.TableComparison of Student Intervention and Control Groups, Paired AnalysesStudy GroupPre-intervention Agreement*Agreement indicates “somewhat agree” or “completely agree”.Post-intervention AgreementP Value†Post- compared with preintervention.End-of-Year AgreementP Value‡End of year compared with preintervention.Intervention group I have the power to address the economic health care crisis.12 (28)23 (53).005§Statistically significant.21 (54).78 I have the resources/means to make cost-conscious decisions.16 (37)24 (56).1027 (69).02§Statistically significant. I would be comfortable initiating a discussion about unnecessary tests or treatments with my team.19 (44)36 (84).000§Statistically significant.30 (77).20 I would be comfortable bringing up cost considerations in discussing patients with my team.26 (60)28 (65).5925 (64).80 I make sure I elicit my patients' goals and preferences when I interact with them.37 (86)38 (88).7434 (87).41 I incorporate my patients' goals and preferences when I make clinical decisions.38 (88)40 (93).4836 (92)1.00 In my clinical decisions, I consider the potential costs to the patient.20 (47)33 (77).003§Statistically significant.32 (82).21 In my clinical decisions, I consider the potential costs to the health care system.10 (23)29 (67).000§Statistically significant.24 (63).01§Statistically significant.Control group I have the power to address the economic health care crisis.25 (42)29 (48).3726 (48).65 I have the resources/means to make cost-conscious decisions.35 (57)30 (49).3528 (52).05§Statistically significant. I would be comfortable initiating a discussion about unnecessary tests or treatments with my team.28 (47)31 (52).5330 (57).68 I would be comfortable bringing up cost considerations in discussing patients with my team.37 (62)30 (50).1329 (55).06 I make sure I elicit my patients' goals and preferences when I interact with them.54 (89)54 (89)1.0046 (85).16 I incorporate my patients' goals and preferences when I make clinical decisions.52 (87)56 (93).2547 (89).53 In my clinical decisions, I consider the potential costs to the patient.46 (77)47 (78).8141 (77).81 In my clinical decisions, I consider the potential costs to the health care system.33 (55)41 (68).1030 (57)1.00Values are number (percentage).* Agreement indicates “somewhat agree” or “completely agree”.† Post- compared with preintervention.‡ End of year compared with preintervention.§ Statistically significant. Open table in a new tab Values are number (percentage). In the control group, paired analyses in the self-efficacy statements showed no change after clerkship but did show a decreased frequency of agreement with the statement, “I have the resources/means to make cost-conscious decisions” (P = .050) at end of year. Value self-audits across sites differed from each other, with the highest proportion of value presentations at PSUCOM (P = .014), with similar types of value discussions across sites (Appendix B, available online). Several themes emerged from focus group discussions. Students articulated that one benefit of SOAP-V was that it embedded the concept of value into their thinking and empowered them to apply the framework in both inpatient and outpatient experiences, as well as in other clerkships. They reported becoming more cost-conscious and more comfortable with risk/benefit discussions. Many students remarked that SOAP-V training helped them find resources about relative costs that were often “invisible” to members of the team. Barriers to SOAP-V implementation included lack of cultural “buy-in” by residents and faculty and limited time. A table with themes and representative comments is available in Appendix C (available online). We found that teaching third-year medical students in their medicine clerkships to use the SOAP-V framework positively impacted their self-efficacy to apply several HVC principles. At the end of clerkship, the intervention group students felt more comfortable in initiating a discussion about unnecessary tests or treatments with their team and were more likely to consider potential costs for the patient and the health care system compared with control group students. They felt more equipped to make cost-conscious medical decisions. Students did report an uptake of value discussions into teaching rounds. Interestingly, intervention and control students did not feel more comfortable specifically bringing up cost issues during rounds and indicated a lack of buy-in as a reason. Additionally, we suspect that specific discussions of costs may be fraught with anxiety and uncertainty for students who are attempting to fit in with the free-spending health care culture. Our findings were consistent with the guiding principles of our tool. SOAP-V combines the well-established concepts of evidence-based medicine and patient-centered care with the less common consideration of cost into a memorable and intuitive framework. The training session elevated their awareness about value; Healthcare Bluebook gave them access to cost data; and SOAP-V provided them with a framework to integrate value discussions into rounds. These factors may have been synergistic in influencing student self-efficacy. Our quantitative and qualitative results showed that some concepts from our SOAP-V training persisted to the end of the academic year. The SOAP format is not limited to internal medicine; it is a universal format for progress notes and presentations in all clerkship settings. As such, SOAP-V can be intimately linked to the daily activities of medical students, consistent with educational theories in which “educational innovation embedded in process change” can play a transformative role in learning.23Sklar D.P. How medical education can add value to the health care delivery system.Acad Med. 2016; 91: 445-447Crossref PubMed Scopus (11) Google Scholar One secondary finding was that whereas the students in the control group had a significant decline in their perception that they have the resources and means to make cost-conscious decisions, the students in the intervention group had an upward trend at the end of clerkship and a significant increase by year end. Although this difference may be due to chance, it is possible that empowering students with tools to make HVC decisions may help to minimize the erosion of idealism and perceived self-efficacy, at least in the HVC domain, during a time in which stress, uncertainty, and intense acculturation contribute to the loss of optimism.24Griffith C.H. Wilson J.F. The loss of student idealism in the 3rd-year clinical clerkships.Eval Health Prof. 2001; 24: 61-71Crossref PubMed Scopus (85) Google Scholar, 25Woloschuk W. Harasym P.H. Temple W. Attitude change during medical school: a cohort study.Med Educ. 2004; 38: 522-534Crossref PubMed Scopus (240) Google Scholar, 26Hojat M. Vergare M.J. Maxwell K. et al.The devil is in the third year: a longitudinal study of erosion of empathy in medical school.Acad Med. 2009; 84: 1182-1191Crossref PubMed Scopus (916) Google Scholar, 27Mader E.M. Roseamelia C. Morley C.P. The temporal decline of idealism in two cohorts of medical students at one institution.BMC Med Educ. 2014; 14: 58Crossref PubMed Scopus (29) Google Scholar Single-institution studies have revealed similar opportunities and challenges in teaching HVC to learners. The principle of using grassroots efforts28Ryskina K.L. Smith C.D. Weissman A. et al.U.S. internal medicine residents' knowledge and practice of high-value care: a national survey.Acad Med. 2015; 90: 1373-1379Crossref PubMed Scopus (25) Google Scholar, 29Ashok A. Combs B. Teaching high-value care.AMA J Ethics. 2015; 17: 1040-1043Crossref PubMed Scopus (3) Google Scholar, 30Shah N. Levy A.E. Moriates C. Arora V.M. Wisdom of the crowd: bright ideas and innovations from the teaching value and choosing wisely challenge.Acad Med. 2015; 90: 624-628Crossref PubMed Scopus (18) Google Scholar is evidenced in Muntz's project, in which students are deputized as change agents in enforcing Choosing Wisely practices.14Muntz M. Thomas J. Quirk K. Thapa B. Frank M. Clerkship students as high-value care officers increased awareness and practice of cost-conscious care. Abstracts from the Proceedings of the 2014 Annual Meeting of the Clerkship Directors of Internal Medicine (CDIM).Teach Learn Med. 2015; 27: 349-350Google Scholar Tartaglia's analysis of student experiences with cost-conscious care resonates with ours in that it highlighted “speaking up during rounds” as a primary strategy to incorporate value into decision making and identified time, effort, and ingrained practices as barriers.11Tartaglia K.M. Kman N. Ledford C. Medical student perceptions of cost-conscious care in an internal medicine clerkship: a thematic analysis.J Gen Intern Med. 2015; 30: 1491-1496Crossref PubMed Scopus (21) Google Scholar We propose that this “bottom-up” approach, using medical students and residents to transform the culture by gradual diffusion, represents a promising model for long-term change in physician HVC behaviors. Limitations to our study include using institutions invested in HVC. Our outcomes centered on student self-efficacy rather than on objective measurement of behaviors or clinical outcomes. Students ranked site preferences, so groups were not randomized. Although differences between groups were modest, there may be unmeasured differences that could impact changes in HVC attitudes. Although all students were exposed to academic practices, unexplored site-specific differences in practice patterns and other hidden curricula might have influenced student attitudes. We experienced significant subject attrition in our measurements for several reasons: online surveys resulted in lower response rates compared with in-person paper-based surveys; repeat measurements resulted in lower response rates; and students did not always report identifier codes. Secular trends in institutions to focus on HVC may have magnified our results. Finally, our focus group participants were nonrandomized, which may have caused selection bias. SOAP-V is an effective and practical framework for teaching HVC. It creates a mindset of value in medical students. To test the generalizability of this framework for residents, we are currently studying the implementation of SOAP-V in 2 internal medicine residencies. Our hope is that once SOAP-V is embedded into presentations, every conversation, every case discussion, and every decision can focus appropriately on value that leads to improved outcomes for patients.