By Eileen M. Moser, MD, MHPE; Sara Fazio, MD; Grace Huang, MD; Susan Glod, MD; Clifford Packer, MD
“It’s important to teach the principles of cost-conscious, high-value care, but how do we enable our medical students to actually practice it?” This question gripped our group of clinician educators gathered at the Millennium Conference on Teaching Value-Added Care (HVC) in 2013. Students needed authentic opportunities to apply HVC knowledge and practice HVC skills. Additionally, our own institutions needed to prepare for the shift from fee-based care to value-based care. We had a big idea: medical students would not only practice HVC, but they would also serve as change agents at our teaching hospitals to encourage HVC.
We acknowledged many obstacles to teaching students about HVC. Most clinical faculty who teach medical students during patient care delivery have not been trained in HVC. “Value” frequently does not enter the busy clinician’s mindset and consequently, students may not observe HVC being modeled. Our current health care environment emphasizes action, through sophisticated tests and invasive procedures, without meaningful consideration of the risk of harm to patients. Given the rapid pace of clinical care, it is no surprise that the clinician educator would find it challenging to remember to teach HVC during patient care activities. We needed to develop a method to remind students and their teachers to consider value and to embed that process in their workflow.
SOAP-V emerged as a modification of traditional “SOAP” presentation (Subjective-Objective-Assessment-Plan), adding “V” for value. This framework creates a cognitive forcing function to promote discussion of HVC during patient care delivery. The SOAP-V model prompts students to consider several questions: 1) Before choosing an intervention, have I considered whether the result would change management? 2) Have I incorporated the patient’s goals and values, and considered the potential harm of the intervention compared to alternatives? 3) What is the known and potential cost of the intervention, both immediate and downstream?
In the summer of 2014, we collaborated to implement SOAP-V for third-year medical students during their internal medicine clerkships at our home medical schools: Penn State College of Medicine, Harvard Medical School and Case Western Reserve University School of Medicine. We developed HVC teaching materials, including a video, PowerPoint presentation and role-playing exercise that could be taught within 45 minutes. The students received a SOAP-V card and the HealthCareBluebook.com Web address to research costs, and then used SOAP-V during patient rounds in the hospital.
Biweekly surveys and direct observation confirmed that third-year medical students are using the SOAP-V tool at our medical schools. Trained students report increased comfort in initiating discussions about unnecessary tests or treatments with their teams, increased power to address the economic health care crisis and increased consideration of potential costs to the health care systems when making clinical decisions compared to the control group of students who did not receive the SOAP-V intervention.
By using SOAP-V, medical students can demonstrate the application of HVC on teams to both resident and attending physicians. Our next steps will be to gauge whether resident and faculty attitudes about HVC have changed, as well as to embed SOAP-V in other clerkships, and to promote the use of the SOAP-V tool within corresponding residencies.
Drs. Eileen Moser and Susan Glod from Penn State Milton S. Hershey Medical Center; Drs. Sara Fazio and Grace Huang from Harvard Medical School; and Dr. Clifford Packer from Case Western Reserve University and the Louis Stokes Cleveland VA Medical Center, modified the traditional SOAP note template to include a discussion of value. The team was a winner of the 2nd Annual Teaching Value and Choosing Wisely Challenge.