BACKGROUND:The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described. OBJECTIVE:To explore pediatric residents' experiences with HVC and its facilitators and barriers. METHODS:We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached. RESULTS:Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants. CONCLUSIONS:Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.

Introduction: Confidence-weighted testing assesses learners’ beliefs about their knowledge and skills. As part of a hospital-wide quality improvement initiative to enhance care for pediatric patients with suspected sepsis, we developed a novel intervention using confidence-weighted testing to identify institutional areas of misinformation and knowledge gaps while also providing real-time feedback to individual learners. Methods: We developed pediatric sepsis eLearning modules incorporating confidence-weighted testing. We distributed them to nurses, advanced practitioners, and physicians in emergency departments and acute care/non-intensive care unit inpatient settings in our hospital system. We analyzed completion and response data over 2 years following module distribution. Our outcomes included completion, confidently held misinformation (CHM; when a learner answers a question confidently but incorrectly), struggle (when a learner repeatedly answers a question incorrectly or with low confidence), and mastery (when a learner initially answers a question correctly and confidently). Results: Eighty-three percent of assigned learners completed the modules (1,463/1,754). Although nurses had significantly more misinformation and struggled more than physicians and advanced practitioners, learners of all roles achieved 100% mastery as part of module completion. The greatest CHM and struggle were found in serum lactate interpretation’s nuances and the hemodynamic shock states commonly seen in sepsis. Conclusions: Our novel application of confidence-weighted testing enhanced learning by correcting learners’ misinformation. It also identified systems issues and institutional knowledge gaps as targets for future improvement.

A 19-month-old boy with a medical history of 1 febrile seizure presented to the emergency department (ED) with 2 days of vomiting and 1 day of diarrhea. He was accompanied by his non–English-speaking mother, who reported several episodes of nonbloody, nonbilious emesis and dark brown, watery stools. The patient had decreased intake of solid foods, but he had been breastfeeding well. Because of his diarrhea, the patient’s mother was unsure how many voids he had had in the past day. He had not had fevers. The family history was significant for the patient’s father recently being diagnosed with hepatitis C. The patient’s mother brought him into the ED because of his symptoms and concern that he looked “yellow.”In the ED, the patient was afebrile with normal vital signs for his age (including heart rate of 146 beats per minute), and he was “well appearing and active” with moist mucous membranes and a capillary refill of <2 seconds. However, the ED provider additionally documented that the patient appeared “moderately dehydrated [and] slightly jaundiced,” and he ordered a comprehensive metabolic panel (CMP). All values were within normal limits, including total bilirubin, except for a low bicarbonate of 16 mmol/L (normal 21–30 mmol/L) and an elevated alkaline phosphatase (ALP) of 926 U/L (normal 129–291 U/L). The provider consulted endocrinology for the elevated ALP, who noted a broad differential for elevated ALP and that transient hyperphosphatasemia is a diagnosis of exclusion. They recommended checking 25-hydroxyvitamin D, phosphate, and parathyroid hormone to evaluate for underlying parathyroid, vitamin D, and bone disease. They also wrote that the team could check total and isoenzymes of ALP “if desiring further testing to help confirm [the] diagnosis of transient hyperphosphatasemia.” The ED provider obtained these recommended laboratories, including the ALP laboratories, as well as a gamma-glutamyl transferase, acute …