Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity

Andrea N. Leep Hunderfund, Stephanie R. Starr, Liselotte N. Dyrbye, Elizabeth G. Baxley, Jed D. Gonzalo, Bonnie M. Miller, Paul George, Helen K. Morgan, Bradley L. Allen, Ari Hoffman, Tonya L. Fancher, Jay Mandrekar, Darcy A. Reed

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background: Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. Objectives: To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). Design: Multisite cross-sectional survey Participants: Third- and fourth-year students at nine US medical schools Main Measures: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. Key Results: Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04–1.38; P = 0.01). Conclusions: Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.

Original languageEnglish (US)
Pages (from-to)1131-1138
Number of pages8
JournalJournal of general internal medicine
Issue number7
StatePublished - Jul 15 2019


  • cost-conscious care
  • high-value cost-conscious care
  • medical students
  • survey
  • undergraduate medical education

ASJC Scopus subject areas

  • Internal Medicine


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