Residency is like the adolescence of medical training. Residents are testing boundaries, learning their limits, and developing their diagnostic and therapeutic skills. Much like a young bear learning to fish, residents learn by doing under the close supervision of a faculty physician. Mama bear won’t let her cub starve and faculty won’t let the residents cause harm. When given the chance, however, residents will push those boundaries to the limits in an attempt to best each other. They are, inherently, competitive creatures. Much like the proud bear with a big salmon, the resident with the rarest diagnosis or the most abnormal lab value becomes the alpha doctor. At Yale School of Medicine, we leverage this competitive atmosphere to engage residents in learning and education.
The Interactive Cost-Awareness Resident Exercise (I-CARE) is a case-based, clinical-education initiative to introduce cost awareness into internal medicine residency programs. It features minimal start-up costs, high ease of use, and is easily replicated in other institutions. We adapted our standard chief resident-driven morning report to include institution-specific charge data without removing any clinical didactic education. What has resulted from these report changes is a monthly week-long competition that engages both faculty and trainees. The key to the success of I-CARE is capitalizing on residents’ competitive natures to focus their energy in a positive, educational manner.
Our session usually runs for an hour and is fairly straightforward. The session is prepared by a chief resident, who pulls a case study from the literature, typically the New England Journal of Medicine, and prepares a PowerPoint presentation with the relevant history, initial physical exam, and any other pertinent information. Then the trainees, working together as a group, direct the work-up by asking for specific testing and procedures or any additional history and physical exam maneuvers. The real charge for each test is known and recorded in real time by the chief—exam maneuvers and history items are free. When the trainees reach a diagnosis based on their testing, they provide their diagnosis to the chief, learn if they are correct and, time allowed, receive a short didactic session on the topic. Finally, the residents receive their total expenditures before returning to the wards to continue the work of the day. Yes—at the end of the session, the group gets a bill for their work-up to learn about the cost of the procedures ordered in the case.
What makes I-CARE unique is the structure of the sessions: Each session is closed-door and limited to a specific level of training (interns, students, residents). More important, the sessions are duplicated at each of three training sites for our residency program to provide comprehensive learning. After all trainees have participated, the faculty attending physicians participate in the same session. In this case, the doors are flung open and all trainees are invited to observe.
Eventually, after all the dust settles, the results are released—which group got the diagnosis correct and how much money they spent. The curtains are cast aside and friendly competition becomes the name of the game. Residents don’t like losing to other residents, but they really hate losing to the interns. The event has become very popular, with the wards buzzing on the case. Trainee engagement is matched by that of our faculty. One of our elder statesmen, an incredible diagnostician who has been on the faculty for five decades, openly expressed his delight about this exercise. One morning, learning that the educational session of the day was I-CARE, he beamed a bright smile as, his hands folded before him, he called out, “I’ve waited my whole career for this!”
The economics of health care are increasingly important to our profession. The goal of I-CARE is exposure to real financial data and understanding of the business side of the industry in which residents will soon practice. With any luck, current trainees will have a better grasp of that knowledge than we do, and perhaps a small part of that is due to programs like I-CARE. If clinicians cannot understand and identify the fundamental principles of health care finance and economics, we are all in for a world of hurt.
Robert L Fogerty, MD, MPH is an Assistant Professor at Yale School of Medicine. He can be reached at firstname.lastname@example.org. Follow him on Twitter at @RobertFogerty.