Standardized-patient training is no cure for unnecessary image ordering

Primary care residents learning to better handle iffy patient requests by using standardized patients (SPs)—i.e., instructors portraying patients for training purposes—are more satisfied with the resulting interventions. However, they do no better at ordering fewer exams deemed to be of low value by Choosing Wisely guidelines.

Joshua J. Fenton, MD, MPH, of the University of California, Davis, and colleagues arrived at the conclusion after analyzing the decisions and actions of 61 randomized primary-care residents who conducted simulated interventions on SPs during unannounced doctor visits.

The SPs asked for imaging on three prime Choosing Wisely targets—spinal MRI for low back pain, neuro CT for headaches or screening dual-energy x-ray absorptiometry for osteoporosis.

The intervention group received personalized feedback from the SPs after the SPs broke out of their roles.

The control group conducted SP visits without feedback and were emailed relevant clinical guidelines.

The SP-trained residents proved no better than the control group at improving patient-centeredness as measured by appropriate application of six patient-centered techniques, all targeted to address patient concerns without ordering low-value tests.

The study appeared online Dec. 7 in JAMA Internal Medicine.

Of the 61 internal- and family-medicine residents (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up.

The residents ordered low-value tests in 41 SP encounters (26.5 percent) with no significant difference in the odds of test ordering in intervention subjects relative to control group subjects (adjusted odds ratio, 1.07).

Meanwhile, compared with control subjects, intervention subjects had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 vs 43.7) and used virtually the same number of targeted techniques (5.4 vs 5.4 on a scale of 0 to 9).

Rates of test ordering among intervention and control groups were similar for all three SP-requested exams.

The only positive finding was that the intervention group rated visit satisfaction higher—8.5 over 7.8 on a scale from 0 to 10.

Still, despite considerable stated enthusiasm over the quality and relevance of the SP intervention, the intervention “did not affect either patient-centeredness of interactions or the use of targeted counseling techniques, nor did it reduce diagnostic test ordering either for SPs or for actual patients,” the authors write in their discussion.

“Although the intervention was theoretically grounded and rated favorably by residents,” conclude Fenton et al., “an SP [instructor] intervention with such limited scope and duration cannot be recommended as a means of improving the value of diagnostic testing in primary care.”

The Fenton study is one of several focused on medical-education research in the current issue of JAMA Internal Medicine. In an accompanying opinion piece, Sara Fazio, MD, of Harvard and Alwin Steinmann, MD, of the University of Colorado write:

“Internal medicine residents should learn to deliver high-quality, cost-effective, equitable care that is patient-centered as well as to function as part of an interprofessional team. Residents should accomplish these goals while being responsible for an ever-expanding evidence base in the setting of universal and immediate access to medical information by their patients. A competency-based assessment system should assure faculty as well as the public that residency programs in internal medicine are producing the best doctors for the 21st century.”