Exploring Drivers of Medical Overuse Through Transformation of Grand Rounds Into “Right Care Rounds”

Setting and Problem

Medical overuse is a significant problem, and existing curricula for teaching residents about high-value care are inadequate to meet learner needs. It has been shown that the location where a resident trains is correlated with the ability to provide appropriately conservative care and, thus, presents an opportunity to shape a physician's behavior early in the educational process.¹

Intervention

This challenge of medical overuse has been recognized by the Lown Institute in Brookline, Massachusetts, as well as by educators at the Cambridge Health Alliance in Cambridge, Massachusetts, and has given rise to a new educational conference format called “Right Care Rounds.” This conference uses the familiar format of a case presentation to explore and identify drivers of medical overuse and the associated harms in an individual patient case. Goals for Right Care Rounds include helping clinicians recognize and avoid overuse before it occurs, ensuring that the whole patient and the entire continuum of care are considered, and identifying opportunities for improving the quality of care. The Lown Institute provides a framework for the structure of Right Care Rounds (http://lowninstitute.org/take-action/right-care-rounds) and encourages institutions to tailor them to their environment. The case presentation format can be fitted into existing educational time slots such as morning reports, noon conferences, or grand rounds.

A recent presentation of Right Care Rounds at the University of Colorado Division of General Internal Medicine used the style of a morbidity and mortality (M&M) conference to present a case of overuse. The case involved a middle-aged man with history of chronic low-back pain treated with opioid medication; this led to secondary hypogonadism and testosterone supplementation. The conference was conducted with 25 participants, consisting of medical students, internal medicine residents, and internal medicine faculty. Key issues presented were the lack of efficacy data for routine testosterone replacement, secular prescribing trends, new evidence suggesting harm from testosterone replacement, and alternative management options for similar cases in the future. These issues were presented to the audience as a means to identify and reflect on the various drivers of medical overuse.

Outcomes to Date

To meet the Right Care Rounds goal of fostering discussion among participants, we used a familiar cause-and-effect diagram, or “fishbone,” as a cognitive tool (FIGURE). Unlike a typical M&M conference in which these diagrams are used to identify factors contributing to medical error, our conference highlighted medical overuse as the outcome to be avoided and the focus of future quality improvement initiatives. The example was not intended to present an exhaustive list, yet the 5 categories were used to organize potential contributing factors and ultimately included most drivers identified by the audience.

FIGURE .

The Right Care Fishbone

We surveyed the audience using the usual grand rounds evaluation form, a simple 2-item, free-response questionnaire. We asked participants to compare the Right Care Rounds format to prior presentations, and whether the presentation was likely to change practice. Respondents (n = 10) uniformly reported the presentation and discussion to be excellent and indicated that is was likely to positively influence future practice. Although it is difficult to draw conclusions from these preliminary data, the positive response to the Right Care Rounds suggests that this may be an effective method to explore the drivers of medical overuse, the potential harm that results from it, and to offer insight on ways to avoid it in the future.