Stewardship Decisions Among Internal Medicine Residents: Responses to Common Challenges Using Vignettes

Background: Stewardship is an important aspect of medical care to which little formal attention is paid during training. Purpose: The goal is to evaluate stewardship practices of internal medicine residents and the relationship of resident refusal to provide requested nonindicated care with levels of confidence and bother. Methods: Cross-sectional survey of residents in one training program, containing four hypothetical clinical scenarios asking residents whether they would provide nonindicated tests and treatments, and to report confidence in the decision and bother. Results: Sixty-seven of 105 residents completed the survey. Most residents prescribed a requested brand-name expensive medication when a generic was available and hospitalized a patient with no expected clinical benefit, but few were willing to repeat imaging for quicker availability or perform an unnecessary diagnostic evaluation. Residents ordering nonindicated tests and treatments reported lower confidence in their decision and more bother. PGY level was not associated with clinical decision or bother. Conclusions: Internal medicine residents, at least on hypothetical scenarios, demonstrate inconsistent stewardship practices. Findings support room for improvement in confidence when faced with requests for nonindicated care and suggest the need for greater curricular emphasis on stewardship.