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

  • Andrea N. Leep HunderfundEmail author
  • 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



Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns.


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).


Multisite cross-sectional survey


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).


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.


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



Regional healthcare intensity data from the End-of-Life Chronic Illness Care database were obtained from The Dartmouth Atlas, which is funded by the Robert Wood Johnson Foundation and the Dartmouth Clinical and Translational Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).


This study was prepared with financial support from the American Medical Association as part of the Accelerating Change in Medical Education initiative, and all participating schools received grants through this initiative (see for further details).

Compliance with Ethical Standards

The institutional review board (IRB) at each participating school approved or exempted this study.

Conflicts of Interest

Dr. Gonzalo reports receiving support from the Josiah Macy Foundation, American Medical Association, and Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Dr. Fancher reports support from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP29965, Academic Units for Primary Care Training and Enhancement, for $3,741,116. This information or content and conclusions of this manuscript are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. All remaining authors declare that they do not have a conflict of interest.


The content reflects the views of the authors.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Andrea N. Leep Hunderfund
    • 1
    Email author
  • Stephanie R. Starr
    • 1
  • Liselotte N. Dyrbye
    • 1
  • Elizabeth G. Baxley
    • 2
  • Jed D. Gonzalo
    • 3
  • Bonnie M. Miller
    • 4
  • Paul George
    • 5
  • Helen K. Morgan
    • 6
  • Bradley L. Allen
    • 7
  • Ari Hoffman
    • 8
  • Tonya L. Fancher
    • 9
  • Jay Mandrekar
    • 1
  • Darcy A. Reed
    • 1
  1. 1.Mayo Clinic, NeurologyRochesterUSA
  2. 2.East Carolina UniversityGreenvilleUSA
  3. 3.Pennsylvania State UniversityHersheyUSA
  4. 4.Vanderbilt UniversityNashvilleUSA
  5. 5.Brown UniversityProvidenceUSA
  6. 6.University of MichiganAnn ArborUSA
  7. 7.Indiana University School of MedicineIndianapolisUSA
  8. 8.University of California, San FranciscoSan FranciscoUSA
  9. 9.University of California DavisSacramentoUSA

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