title: Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences With Cost-Conscious Care.
abstract: To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care.
  
  
  
  Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index.
  
  
  
  Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001).
  
  
  
  Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.
authors.affiliation: A.N. Leep Hunderfund is assistant professor of neurology, Mayo Clinic, Rochester, Minnesota. L.N. Dyrbye is professor of medical education and medicine, Mayo Clinic, Rochester, Minnesota. S.R. Starr is assistant professor of pediatric and adolescent medicine and director, Science of Health Care Delivery Education, Mayo Medical School, Mayo Clinic, Rochester, Minnesota. J. Mandrekar is professor of biostatistics and neurology, Mayo Clinic, Rochester, Minnesota. J.M. Naessens is professor of health services research, Mayo Clinic, Rochester, Minnesota. J.C. Tilburt is professor of medicine and associate professor of biomedical ethics, Mayo Clinic, Rochester, Minnesota. P. George is associate professor of family medicine and associate professor of medical science, Warren Alpert Medical School, Brown University, Providence, Rhode Island. E.G. Baxley is professor of family medicine and senior associate dean of academic affairs, Brody School of Medicine, East Carolina University, Greenville, North Carolina. J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Pennsylvania State University College of Medicine, Hershey, Pennsylvania. C. Moriates is assistant clinical professor, Division of Hospital Medicine, and director, Caring Wisely Program, University of California San Francisco, San Francisco, California. S.D. Goold is professor of internal medicine and health management, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan. P.A. Carney is professor of family medicine and of public health and preventive medicine, Oregon Health & Science University, Portland, Oregon. B.M. Miller is professor of medical education and administration, professor of clinical surgery, associate vice chancellor for health affairs, and senior associate dean for health sciences education, Vanderbilt University, Nashville, Tennessee. S.J. Grethlein is professor of clinical medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana. T.L. Fancher is associate professor of medicine, Division of General Medicine, University of California Davis, Sacramento, California. D.A. Reed is associate professor of medical education and medicine and senior associate dean of academic affairs, Mayo Medical School, Mayo Clinic, Rochester, Minnesota.
authors.forename: Andrea N
authors.initials: AN
authors.lastname: Leep Hunderfund
authors.forename: Liselotte N
authors.initials: LN
authors.lastname: Dyrbye
authors.forename: Stephanie R
authors.initials: SR
authors.lastname: Starr
authors.forename: Jay
authors.initials: J
authors.lastname: Mandrekar
authors.forename: James M
authors.initials: JM
authors.lastname: Naessens
authors.forename: Jon C
authors.initials: JC
authors.lastname: Tilburt
authors.forename: Paul
authors.initials: P
authors.lastname: George
authors.forename: Elizabeth G
authors.initials: EG
authors.lastname: Baxley
authors.forename: Jed D
authors.initials: JD
authors.lastname: Gonzalo
authors.forename: Christopher
authors.initials: C
authors.lastname: Moriates
authors.forename: Susan D
authors.initials: SD
authors.lastname: Goold
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Carney
authors.forename: Bonnie M
authors.initials: BM
authors.lastname: Miller
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Grethlein
authors.forename: Tonya L
authors.initials: TL
authors.lastname: Fancher
authors.forename: Darcy A
authors.initials: DA
authors.lastname: Reed
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003363:Cost Control; D003430:Cross-Sectional Studies; D005260:Female; D005843:Geography; D017048:Health Care Costs; D006801:Humans; D016365:Liability, Legal; D016014:Linear Models; D008297:Male; D008318:Malpractice; D010819:Physician's Role; D013337:Students, Medical; D011795:Surveys and Questionnaires; D014481:United States; D055815:Young Adult