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Comment & Response
May 2019

Analyze Patient Tests for Importance Before Ordering—Reply

Author Affiliations
  • 1Columbia University Medical Center, New York, New York
  • 2Weill Cornell Medical College, New York, New York
  • 3Drexel University College of Medicine, Philadelphia, Pennsylvania
JAMA Intern Med. 2019;179(5):730-731. doi:10.1001/jamainternmed.2018.8336

In Reply Dr Horowitz’s advice should be well heeded by physicians, especially residents and those training them. Learning from direct experience is critical to what Dr Horowitz calls the “formation of theories” and to all physicians improving their own performance. We certainly agree that learning about individual tests and testing strategies that have important implications for patients is a critical part of becoming a high-value care physician.

Our plight, however, is finding a way to maximize learning from one’s own experience in the modern era when so much information is available. The electronic health records that nearly all trainees work with daily offer an incredible opportunity to detect trends and conduct research that wasn’t possible in prior eras. Currently, most attending physicians observe residents over 2- or 4-week periods during which time they can evaluate residents’ individual decisions but probably cannot observe long-term trends with any degree of confidence. This paradigm is based on the hope that the feedback attending physicians provide, when accumulated across multiple rotations and multiple attending physicians, is sufficient to judge the performance of residents. Perhaps now, using electronic health record data, we can start to provide objective performance feedback to residents.

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