Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial | Radiology | JAMA Internal Medicine

<!DOCTYPE html> <html id="doc" lang="en" class="page-article"> <head id="Head1">  <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <script> var SCM = SCM || {}; if (SCM.AMA && SCM.AMA.DataLayerAsync) { SCM.AMA.DataLayerAsync.push("arrSisAffinity", "", "array"); SCM.AMA.DataLayerAsync.push("SubStatus", "no", "string"); } var googletag = window.googletag || {}; googletag.cmd = googletag.cmd || []; if (typeof Storage !== "undefined") { var targetingParamStr = localStorage.getItem("bcDFPTargetingParams"); if (targetingParamStr) { var targetingParameters = JSON.parse(targetingParamStr); // set page-level targeting parameters jQuery.each(targetingParameters, function (index, param) { googletag.cmd.push(function () { window.googletag.pubads().setTargeting(param.key, param.value); }); }); } } if (!googletag.pubads) { (function () { var gads = document.createElement('script'); var useSSL = 'https:' == document.location.protocol; gads.src = (useSSL ? 'https:' : 'http:') + '//securepubads.g.doubleclick.net/tag/js/gpt.js'; gads.setAttribute("async", ""); gads.setAttribute("defer", ""); var node = document.getElementsByTagName('script')[0]; node.parentNode.insertBefore(gads, node); })(); var App = App || {}; App.Ads = App.Ads || {}; App.Ads.adPath = App.Ads.adPath || '/6479/' + 'ama.archinte'; App.Ads.Mappings = App.Ads.Mappings || {}; App.Ads.slots = App.Ads.slots || []; App.Ads.fromGoogle = !('yes' === 'yes'); App.isCollection = App.isCollection || !!document.getElementsByClassName('pg_collection').length; googletag.cmd.push(function () { googletag.pubads() .setTargeting('environment', ['newjama']) .setTargeting('site', ['ama.archinte']) .setTargeting('sect', ['scholarly']) .setTargeting('sub', ['no']) .setTargeting('device', ['Mozilla%2F4.0%20%28compatible%3B%20MSIE%207.0%3B%20Windows%20NT%206.0%3B%20SLCC1%3B%20.NET%20CLR%202.0.50727%3B%20.NET%20CLR%203.0.04506%3B%20.NET%20CLR%203.5.21022%3B%20.NET%20CLR%201.0.3705%3B%20.NET%20CLR%201.1.4322%29']) .setTargeting('usaphys', ['no']) .setTargeting('memberstat', ['no']) .setTargeting('pracset', ['']) .setTargeting('specialty', ['other']) .setTargeting('occupation', ['']) .setTargeting('useraffinity', ['']) .setTargeting('direct', ['yes']) .setTargeting('bot', ['']) .setTargeting('datacenter', ['no']) .setTargeting('selfMPA', ['']) .setTargeting('selfSpecialty', ['']); if (App.isCollection) { googletag.pubads().setTargeting('collection', ['']); } var testParam = getQueryVariable('test'); if (testParam) { googletag.pubads().setTargeting('test', [testParam]); } function getQueryVariable(variable) { var query = window.location.search.substring(1); var vars = query.split('&'); for (var i = 0; i < vars.length; i++) { var pair = vars[i].split('='); if (decodeURIComponent(pair[0]) == variable) { return decodeURIComponent(pair[1]); } } } googletag.pubads().disableInitialLoad(); googletag.enableServices(); }); } </script> <meta name="viewport" content="width=device-width, initial-scale=1" /><meta name="format-detection" content="telephone=no" /><link rel="shortcut icon" href="//cdn.jamanetwork.com/UI/app/img/favicons/intemed/favicon.ico"> <link rel="icon" type="image/png" href="//cdn.jamanetwork.com/UI/app/img/favicons/intemed/favicon-192x192.png" sizes="192x192"> <link rel="apple-touch-icon" sizes="180x180" href="//cdn.jamanetwork.com/UI/app/img/favicons/intemed/apple-touch-icon-180x180.png"> <meta http-equiv="X-UA-Compatible" content="IE=Edge" /> <link rel="stylesheet" href="//cdn.jamanetwork.com/UI/app/dist/app.min.css?v=638677764476993385"> <link href="//cdn.jsdelivr.net/chartist.js/latest/chartist.min.css" type="text/css" rel="stylesheet" /> <meta property="og:title" content="Patient-Centered Counseling and Low-Value Diagnostic Tests" /> <meta property="og:type" content="Article" /> <meta property="og:url" content="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472948" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f1.png?Expires=2147483647&Signature=LERXCa-RXYMvtqjXHC5wTSHcGybPAw1sAFVucut2VIFIZMWINP7A3S7xhCnXi9-avGwgu6X8HMtFeQZfgwBwnWcHAL3xwsfKRtirLjzvKsq721WRo-wQWy71qVN5fWT7vVu2d6I9Ils04e~e5-wbCCBPobRwAhbm-VTYvOuPv-yT5ut4V32xuUa0ovNoCwvOBNvNO8~~j0qSqXN2SMJN6cPiTIsoKCAUf4eVF9LtKxRFrdzU8CBGbch1m7Kgmjhh1cT3ZbcMZzR3uKwfFPLtW4Vf7R1fWceyo80MZqMsrNZK6QXLwlFgjAIBgqRgR~sLSbEBEWsGTuhsZ4VjwsN81g__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t1.png?Expires=2147483647&Signature=fbOvUFFE56PRxddPh4vNNZiPDbV~KWv~fV9mQjCFF2WmhOxtNbKqC-ikN4vym0eubZCfGVJ2ryMZEtuldHSMhv6eKUd7f738Sh2Hwzl6iwm9aFRae92cX2SYsqWZwFGMkGCHOAzicvOS2snlO5Sp~8wvO2vQBGnKe3svUxWtiNbVYl-CafAVEPTtSAOfcGBKmBSSlPcCIxLNwZHK94QSriRQ0Th5By0AsszBobYSUwHIjBADY6ToCv3rzrIDZFlbQ5DMPUU78dxLOi2Xkpjl92oa9FI0gAOxk9FQYhF6QtzHUPiWV9nxBg8~q~PshJBIOHtMNAQbVdAXxU6wbakEHg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f2.png?Expires=2147483647&Signature=inqotpDTBsfhsNTwmloRoHVDIyFjhHwHp75aqEoN6uzyPDPycU4qldURYDvI7dFNnMHmAqL6Ijg0u3ssab47-uM27n4D81LIWkx24d8Ig8HR1pp7u6x1WQTDBP9XRORkfeFfoYWwZChILnTxZUeHjpDgXYFW~IFF4IYyjHpEiYBm~ljzCIF98cE2vDQ2fjC0bsHCnY5-PYBQWF2vjLQvS75HxfFcfmgVt3wZiCY3vaagaJTOfeTJYUvNrPPSd1jKZBz7V0aEzPeqBmDgfejx3MasuVD5DPCFoR1T7m8AwgBj53qg-z~y9XnFFktsny54Ilw6txTshPgewMJlETQGiA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t2.png?Expires=2147483647&Signature=RfW5vx~bi9-rMXN7-J~vlWFF7a4fdW-LK7bUv~qahh0Z5XI38wIrGTGmxcDHcVoosH-q8hN6hxveKkJoEmjnzjHxLfO3haVBks0XhtSf~gGau2S-WFIkTE5c88c4p~w7Wbg6bXNFP484fYVu3YMzMGTZw4JcnNCvPjxF6KxpbKN1mjpc1uqbxAlufWR5vaIktoOTpOAr83rq2m1zYvCNH6Z9Ql7850ZYQ4SxaOZA48RAj-ePr1Rp0-GJp5YbiWSKzpi-sY4VWOBLrAl9wQ9FKhSpFYbZWzNxsd~EnpmYkaSvEKBtaKBRBIudIFbAPekcyJljkuDygKVN5AdOXd3OCQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t3.png?Expires=2147483647&Signature=OyxJsJEh2CDfkCYmyfyR8ofjHpmpa8mXIyxBPXLGOngFEL584dHOZtc3YzSD-KTC2XLI30zRiUfNLJ9aqbYuhCYCWmIEVRqGH5Pwnm36Xg2mB1oxem3a5FiN2YSSZWjkTrHhekveD8kStygv145N~ggbitKVkMcNGNQSb8doWXWS7w0zI1FQwOUCu6MzJeY-rGHNpaCinMwabv~zSlXNa2FuTAfl6yUn8cCJvIJc7X-HcFVUziwVFOpwHs13Xe3JRjr1gZJhJ0r2tUEyWn~eM0l5jRcDbSmE836PGi52-0oPxLx7-qGLJ1QpWXoisDjD7ufEkDax42miPV~yee~kZg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:description" content="This randomized clinical trial evaluates the effectiveness of a standardized patient–based intervention designed to enhance primary care physician patient-centeredness and skill in handling patient requests for low-value diagnostic tests." /> <meta property="fb:pages" content="87087958340" /> <meta property="fb:pages" content="122228711814384" /> <meta property="fb:pages" content="1648414928738217" /> <meta property="fb:pages" content="117506346528" /> <meta property="fb:pages" content="97538728726" /> <meta property="fb:pages" content="114116793520" /> <meta property="fb:pages" content="100679858757" /> <meta property="fb:pages" content="759822190741773" /> <meta property="fb:pages" content="100265333750" /> <meta property="fb:pages" content="234770525256" /> <meta property="fb:pages" content="98784919862" /> <meta property="fb:pages" content="120829458202" /> <meta property="fb:pages" content="124842870398" /> <meta property="fb:pages" content="110245330325636" /> <meta name="twitter:card" content="summary_large_image" /> <meta name="twitter:site" content="@JAMAInternalMed" /> <meta name="twitter:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f1.png?Expires=2147483647&Signature=LERXCa-RXYMvtqjXHC5wTSHcGybPAw1sAFVucut2VIFIZMWINP7A3S7xhCnXi9-avGwgu6X8HMtFeQZfgwBwnWcHAL3xwsfKRtirLjzvKsq721WRo-wQWy71qVN5fWT7vVu2d6I9Ils04e~e5-wbCCBPobRwAhbm-VTYvOuPv-yT5ut4V32xuUa0ovNoCwvOBNvNO8~~j0qSqXN2SMJN6cPiTIsoKCAUf4eVF9LtKxRFrdzU8CBGbch1m7Kgmjhh1cT3ZbcMZzR3uKwfFPLtW4Vf7R1fWceyo80MZqMsrNZK6QXLwlFgjAIBgqRgR~sLSbEBEWsGTuhsZ4VjwsN81g__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <script type="application/ld+json"> { "@context": "https://schema.org/", "@type": "Article", "headline": "Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial", "author": "Joshua J. Fenton, MD, MPH", "url": "https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472948", "datePublished": "2016-02-01", "description": "This randomized clinical trial evaluates the effectiveness of a standardized patient–based intervention designed to enhance primary care physician patient-centeredness and skill in handling patient requests for low-value diagnostic tests.", "publisher": { "@type": "Organization", "name": "JAMA Network", "logo": { "@type": "ImageObject", "url": "//cdn.jamanetwork.com/UI/app/img/favicons/intemed/favicon.ico" } }, "image": [ "https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f1.png?Expires=2147483647&Signature=LERXCa-RXYMvtqjXHC5wTSHcGybPAw1sAFVucut2VIFIZMWINP7A3S7xhCnXi9-avGwgu6X8HMtFeQZfgwBwnWcHAL3xwsfKRtirLjzvKsq721WRo-wQWy71qVN5fWT7vVu2d6I9Ils04e~e5-wbCCBPobRwAhbm-VTYvOuPv-yT5ut4V32xuUa0ovNoCwvOBNvNO8~~j0qSqXN2SMJN6cPiTIsoKCAUf4eVF9LtKxRFrdzU8CBGbch1m7Kgmjhh1cT3ZbcMZzR3uKwfFPLtW4Vf7R1fWceyo80MZqMsrNZK6QXLwlFgjAIBgqRgR~sLSbEBEWsGTuhsZ4VjwsN81g__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t1.png?Expires=2147483647&Signature=fbOvUFFE56PRxddPh4vNNZiPDbV~KWv~fV9mQjCFF2WmhOxtNbKqC-ikN4vym0eubZCfGVJ2ryMZEtuldHSMhv6eKUd7f738Sh2Hwzl6iwm9aFRae92cX2SYsqWZwFGMkGCHOAzicvOS2snlO5Sp~8wvO2vQBGnKe3svUxWtiNbVYl-CafAVEPTtSAOfcGBKmBSSlPcCIxLNwZHK94QSriRQ0Th5By0AsszBobYSUwHIjBADY6ToCv3rzrIDZFlbQ5DMPUU78dxLOi2Xkpjl92oa9FI0gAOxk9FQYhF6QtzHUPiWV9nxBg8~q~PshJBIOHtMNAQbVdAXxU6wbakEHg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f2.png?Expires=2147483647&Signature=inqotpDTBsfhsNTwmloRoHVDIyFjhHwHp75aqEoN6uzyPDPycU4qldURYDvI7dFNnMHmAqL6Ijg0u3ssab47-uM27n4D81LIWkx24d8Ig8HR1pp7u6x1WQTDBP9XRORkfeFfoYWwZChILnTxZUeHjpDgXYFW~IFF4IYyjHpEiYBm~ljzCIF98cE2vDQ2fjC0bsHCnY5-PYBQWF2vjLQvS75HxfFcfmgVt3wZiCY3vaagaJTOfeTJYUvNrPPSd1jKZBz7V0aEzPeqBmDgfejx3MasuVD5DPCFoR1T7m8AwgBj53qg-z~y9XnFFktsny54Ilw6txTshPgewMJlETQGiA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t2.png?Expires=2147483647&Signature=RfW5vx~bi9-rMXN7-J~vlWFF7a4fdW-LK7bUv~qahh0Z5XI38wIrGTGmxcDHcVoosH-q8hN6hxveKkJoEmjnzjHxLfO3haVBks0XhtSf~gGau2S-WFIkTE5c88c4p~w7Wbg6bXNFP484fYVu3YMzMGTZw4JcnNCvPjxF6KxpbKN1mjpc1uqbxAlufWR5vaIktoOTpOAr83rq2m1zYvCNH6Z9Ql7850ZYQ4SxaOZA48RAj-ePr1Rp0-GJp5YbiWSKzpi-sY4VWOBLrAl9wQ9FKhSpFYbZWzNxsd~EnpmYkaSvEKBtaKBRBIudIFbAPekcyJljkuDygKVN5AdOXd3OCQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t3.png?Expires=2147483647&Signature=OyxJsJEh2CDfkCYmyfyR8ofjHpmpa8mXIyxBPXLGOngFEL584dHOZtc3YzSD-KTC2XLI30zRiUfNLJ9aqbYuhCYCWmIEVRqGH5Pwnm36Xg2mB1oxem3a5FiN2YSSZWjkTrHhekveD8kStygv145N~ggbitKVkMcNGNQSb8doWXWS7w0zI1FQwOUCu6MzJeY-rGHNpaCinMwabv~zSlXNa2FuTAfl6yUn8cCJvIJc7X-HcFVUziwVFOpwHs13Xe3JRjr1gZJhJ0r2tUEyWn~eM0l5jRcDbSmE836PGi52-0oPxLx7-qGLJ1QpWXoisDjD7ufEkDax42miPV~yee~kZg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" ], "articleSection": [ "Introduction", "Methods", "Design and Setting", "Participants", "Intervention and Control Conditions", "SP Measurement Visits", "Fidelity Monitoring", "Main Outcome Measures", "Exploratory Outcomes", "PCP Variables", "Sample Size", "Statistical Analysis", "Results", "Discussion", "Conclusions", "Article Information" ], "keyWords": "neuroimaging, osteoporosis, physician-patient relations, primary care physicians, magnetic resonance imaging, x-ray computed tomography, headache, counseling, education, medical, graduate, internship and residency, intervention studies, patient education (procedure), patient simulation, patient-centered care, screening procedure, x-ray absorptiometry, dual-energy, imaging of spine, medical residencies, physician/health practitioner order, educational intervention, overtreatment, response to intervention, unnecessary..." } </script> <meta name="citation_author" content="Joshua J. Fenton" /><meta name="citation_author_institution" content="Department of Family and Community Medicine, University of California–Davis, Sacramento" /><meta name="citation_author_institution" content="Center for Healthcare Policy and Research, University of California–Davis, Sacramento" /><meta name="citation_author" content="Richard L. Kravitz" /><meta name="citation_author_institution" content="Center for Healthcare Policy and Research, University of California–Davis, Sacramento" /><meta name="citation_author_institution" content="Department of Internal Medicine, University of California–Davis, Sacramento" /><meta name="citation_author" content="Anthony Jerant" /><meta name="citation_author_institution" content="Department of Family and Community Medicine, University of California–Davis, Sacramento" /><meta name="citation_author_institution" content="Center for Healthcare Policy and Research, University of California–Davis, Sacramento" /><meta name="citation_author" content="Debora A. Paterniti" /><meta name="citation_author_institution" content="Center for Healthcare Policy and Research, University of California–Davis, Sacramento" /><meta name="citation_author_institution" content="Department of Sociology, University of California–Davis, Sacramento" /><meta name="citation_author" content="Heejung Bang" /><meta name="citation_author_institution" content="Division of Public Health Sciences, University of California–Davis, Sacramento" /><meta name="citation_author" content="Donna Williams" /><meta name="citation_author_institution" content="Department of Internal Medicine, University of California–Davis, Sacramento" /><meta name="citation_author" content="Ronald M. Epstein" /><meta name="citation_author_institution" content="Department of Family Medicine, University of Rochester, Rochester, New York" /><meta name="citation_author_institution" content="Center for Communications and Disparities Research, University of Rochester, Rochester, New York" /><meta name="citation_author" content="Peter Franks" /><meta name="citation_author_institution" content="Department of Family and Community Medicine, University of California–Davis, Sacramento" /><meta name="citation_author_institution" content="Center for Healthcare Policy and Research, University of California–Davis, Sacramento" /><meta name="citation_title" content="Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial" /><meta name="citation_firstpage" content="191" /><meta name="citation_lastpage" content="197" /><meta name="citation_doi" content="10.1001/jamainternmed.2015.6840" /><meta name="citation_keyword" content="neuroimaging" /><meta name="citation_keyword" content="osteoporosis" /><meta name="citation_keyword" content="physician-patient relations" /><meta name="citation_keyword" content="primary care physicians" /><meta name="citation_keyword" content="magnetic resonance imaging" /><meta name="citation_keyword" content="computed tomography" /><meta name="citation_keyword" content="headache" /><meta name="citation_keyword" content="counseling" /><meta name="citation_keyword" content="education, medical, graduate" /><meta name="citation_keyword" content="internship and residency" /><meta name="citation_keyword" content="intervention studies" /><meta name="citation_keyword" content="patient education" /><meta name="citation_keyword" content="patient simulation" /><meta name="citation_keyword" content="patient-centered care" /><meta name="citation_keyword" content="screening" /><meta name="citation_keyword" content="x-ray absorptiometry, dual-energy" /><meta name="citation_keyword" content="spinal imaging" /><meta name="citation_keyword" content="medical residencies" /><meta name="citation_keyword" content="physician order" /><meta name="citation_keyword" content="educational intervention" /><meta name="citation_keyword" content="overtreatment" /><meta name="citation_keyword" content="response-to-intervention" /><meta name="citation_keyword" content="unnecessary procedures" /><meta name="citation_keyword" content="diagnostic imaging" /><meta name="citation_keyword" content="low-value care" /><meta name="citation_keyword" content="primary outcome measure" /><meta name="citation_keyword" content="internal medicine" /><meta name="citation_keyword" content="academic medical centers" /><meta name="citation_keyword" content="low back pain" /><meta name="citation_keyword" content="primary health care" /><meta name="citation_keyword" content="clinical practice guideline" /><meta name="citation_keyword" content="family medicine" /><meta name="citation_keyword" content="choosing wisely" /><meta name="citation_abstract" content="<h3>Importance</h3><p>Low-value diagnostic tests have been included on primary care specialty societies’ “Choosing Wisely” Top Five lists.</p><h3>Objective</h3><p>To evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests.</p><h3>Design, Setting, and Participants</h3><p>Randomized clinical trial of 61 general internal medicine or family medicine residents at 2 residency-affiliated primary care clinics at an academic medical center in California.</p><h3>Interventions</h3><p>Two simulated visits with SP instructors portraying patients requesting inappropriate spinal magnetic resonance imaging for low back pain or screening dual-energy x-ray absorptiometry. The SP instructors provided personalized feedback to residents regarding use of 6 patient-centered techniques to address patient concerns without ordering low-value tests. Control group physicians received SP visits without feedback and were emailed relevant clinical guidelines.</p><h3>Main Outcomes and Measures</h3><p>The primary outcome was whether resident PCPs ordered SP-requested low-value tests during up to 3 unannounced SP clinic visits over 3 to 12 months follow-up, with patients requesting spinal magnetic resonance imaging, screening dual-energy x-ray absorptiometry, or headache neuroimaging. Secondary outcomes included PCP patient-centeredness and use of targeted techniques (both coded from visit audiorecordings), and SP satisfaction with the visit (0-10 scale).</p><h3>Results</h3><p>Of 61 randomized resident PCPs (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up. Compared with control PCPs, intervention PCPs had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 [95% CI, 42.0 to 45.7] vs 43.7 [95% CI, 41.8 to 45.6], adjusted mean difference, −0.2 [95% CI, −2.9 to 2.5];<i>P</i> = .90) and used a similar number of targeted techniques (5.4 [95% CI, 4.9 to 5.8] vs 5.4 [95% CI, 4.9 to 5.8] on a 0-9 scale, adjusted mean difference, 0 [95% CI, −0.7 to 0.6];<i>P</i> = .96). Residents ordered low-value tests in 41 SP encounters (26.5% [95% CI, 19.7%-34.1%]) with no significant difference in the odds of test ordering in intervention PCPs relative to control group PCPs (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Rates of test ordering among intervention and control PCPs were similar for all 3 SP cases. The SPs rated visit satisfaction higher among intervention than control PCPs (8.5 [95% CI, 8.1-8.8] vs 7.8 [95% CI, 7.5-8.2], adjusted mean difference, 0.6 [95% CI, 0.1-1.1]).</p><h3>Conclusions and Relevance</h3><p>An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents.</p><h3>Trial Registration</h3><p>clinicaltrials.gov Identifier:NCT01808664</p>" /><meta name="citation_journal_title" content="JAMA Internal Medicine" /><meta name="citation_journal_abbrev" content="JAMA Intern Med" /><meta name="citation_volume" content="176" /><meta name="citation_issue" content="2" /><meta name="citation_publication_date" content="2016/02/01" /><meta name="citation_issn" content="2168-6106" /><meta name="citation_publisher" content="American Medical Association" /><meta name="citation_reference" content="citation_title=The “top 5” lists in primary care: meeting the responsibility of professionalism.; citation_author=Good Stewardship Working Group; citation_journal_title=Arch Intern Med; citation_year=2011; citation_volume=171; citation_issue=15; citation_pages=1385-1390; " /><meta name="citation_reference" content="citation_title=Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial.; citation_author=Jarvik JG; citation_author=Hollingworth W; citation_author=Martin B; citation_journal_title=JAMA; citation_year=2003; citation_volume=289; citation_issue=21; citation_pages=2810-2818; " /><meta name="citation_reference" content="citation_title=Overdiagnosis of bone fragility in the quest to prevent hip fracture.; citation_author=Järvinen TL; citation_author=Michaëlsson K; citation_author=Jokihaara J; citation_journal_title=BMJ; citation_year=2015; citation_volume=350; citation_pages=h2088" /><meta name="citation_reference" content="Choosing Wisely: An Initiative of the ABIM Foundation. 2015. http://www.choosingwisely.org/. Accessed July 9, 2015. " /><meta name="citation_reference" content="citation_author=Stewart M; citation_author=Brown JB; citation_author=Weston WW; citation_author=McWhinney IR; citation_author=McWilliam CL; citation_author=Freeman TR; citation_publisher=Radcliffe Medical Press Ltd, Abingdon, England; citation_title=Patient-Centered Medicine: Transforming the Clinical Method.; citation_year=2003; " /><meta name="citation_reference" content="citation_title=Getting to “no”: strategies primary care physicians use to deny patient requests.; citation_author=Paterniti DA; citation_author=Fancher TL; citation_author=Cipri CS; citation_author=Timmermans S; citation_author=Heritage J; citation_author=Kravitz RL; citation_journal_title=Arch Intern Med; citation_year=2010; citation_volume=170; citation_issue=4; citation_pages=381-388; " /><meta name="citation_reference" content="citation_title=Patient-centered communication and diagnostic testing.; citation_author=Epstein RM; citation_author=Franks P; citation_author=Shields CG; citation_journal_title=Ann Fam Med; citation_year=2005; citation_volume=3; citation_issue=5; citation_pages=415-421; " /><meta name="citation_reference" content="citation_title=Interventions for providers to promote a patient-centred approach in clinical consultations.; citation_author=Dwamena F; citation_author=Holmes-Rovner M; citation_author=Gaulden CM; citation_journal_title=Cochrane Database Syst Rev; citation_year=2012; citation_volume=12; citation_pages=CD003267" /><meta name="citation_reference" content="citation_title=Improving physicians’ HIV risk-assessment skills using announced and unannounced standardized patients.; citation_author=Epstein RM; citation_author=Levenkron JC; citation_author=Frarey L; citation_author=Thompson J; citation_author=Anderson K; citation_author=Franks P; citation_journal_title=J Gen Intern Med; citation_year=2001; citation_volume=16; citation_issue=3; citation_pages=176-180; " /><meta name="citation_reference" content="citation_title=Training residents to employ self-efficacy-enhancing interviewing techniques: randomized controlled trial of a standardized patient intervention.; citation_author=Jerant A; citation_author=Kravitz RL; citation_author=Azari R; citation_journal_title=J Gen Intern Med; citation_year=2009; citation_volume=24; citation_issue=5; citation_pages=606-613; " /><meta name="citation_reference" content="citation_title=Shared mind: communication, decision making, and autonomy in serious illness.; citation_author=Epstein RM; citation_author=Street RL; citation_journal_title=Ann Fam Med; citation_year=2011; citation_volume=9; citation_issue=5; citation_pages=454-461; " /><meta name="citation_reference" content="citation_title=What do we mean by partnership in making decisions about treatment?; citation_author=Charles C; citation_author=Whelan T; citation_author=Gafni A; citation_journal_title=BMJ; citation_year=1999; citation_volume=319; citation_issue=7212; citation_pages=780-782; " /><meta name="citation_reference" content="citation_author=Stewart M; citation_author=Ryan BL; citation_publisher=Thames Valley Family Practice Research Unit and Centre for Studies in Family Medicine, London, Ontario, Canada; citation_title=Assessing Communication Between Patients and Physicians: The Measure of Patient-Centered Communication (MPCC); citation_year=2001; " /><meta name="citation_reference" content="Goertz M,Thorson D,Bonsell J,. Adult acute and subacute low back pain . Bloomington, MN : Institute for Clinical Systems Improvement. Updated November 2012. https://www.icsi.org/_asset/bjvqrj/LBP.pdf. Accessed September 7, 2015. " /><meta name="citation_reference" content="Florence R,Allen S,Benedict L,. Diagnosis and treatment of osteoporosis. Bloomington, MN : Institute for Clinical Systems Improvement. Updated July 2013. https://www.icsi.org/_asset/vnw0c3/Osteo.pdf. Accessed September 7, 2015. " /><meta name="citation_reference" content="citation_title=Physicians’ reactions to uncertainty in patient care: a new measure and new insights.; citation_author=Gerrity MS; citation_author=DeVellis RF; citation_author=Earp JA; citation_journal_title=Med Care; citation_year=1990; citation_volume=28; citation_issue=8; citation_pages=724-736; " /><meta name="citation_reference" content="citation_title=Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies.; citation_author=Hade EM; citation_author=Murray DM; citation_author=Pennell ML; citation_journal_title=J Natl Cancer Inst Monogr; citation_year=2010; citation_volume=2010; citation_issue=40; citation_pages=97-103; " /><meta name="citation_reference" content="citation_title=Techniques to improve physicians’ use of diagnostic tests: a new conceptual framework.; citation_author=Solomon DH; citation_author=Hashimoto H; citation_author=Daltroy L; citation_author=Liang MH; citation_journal_title=JAMA; citation_year=1998; citation_volume=280; citation_issue=23; citation_pages=2020-2027; " /><meta name="citation_reference" content="citation_title=Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis.; citation_author=Sistrom CL; citation_author=Dang PA; citation_author=Weilburg JB; citation_author=Dreyer KJ; citation_author=Rosenthal DI; citation_author=Thrall JH; citation_journal_title=Radiology; citation_year=2009; citation_volume=251; citation_issue=1; citation_pages=147-155; " /><meta name="citation_reference" content="citation_title=Impact of IT-enabled intervention on MRI use for back pain.; citation_author=Ip IK; citation_author=Gershanik EF; citation_author=Schneider LI; citation_journal_title=Am J Med; citation_year=2014; citation_volume=127; citation_issue=6; citation_pages=512-518.e1; " /><meta name="citation_reference" content="citation_title=A trial of two strategies to modify the test-ordering behavior of medical residents.; citation_author=Martin AR; citation_author=Wolf MA; citation_author=Thibodeau LA; citation_author=Dzau V; citation_author=Braunwald E; citation_journal_title=N Engl J Med; citation_year=1980; citation_volume=303; citation_issue=23; citation_pages=1330-1336; " /><meta name="citation_reference" content="citation_title=The uncritical use of high-tech medical imaging.; citation_author=Hillman BJ; citation_author=Goldsmith JC; citation_journal_title=N Engl J Med; citation_year=2010; citation_volume=363; citation_issue=1; citation_pages=4-6; " /><meta name="citation_reference" content="citation_title=Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists.; citation_author=Kachalia A; citation_author=Berg A; citation_author=Fagerlin A; citation_journal_title=Ann Intern Med; citation_year=2015; citation_volume=162; citation_issue=2; citation_pages=100-108; " /><meta name="citation_reference" content="citation_title=Connoisseurs of care? unannounced standardized patients’ ratings of physicians.; citation_author=Srinivasan M; citation_author=Franks P; citation_author=Meredith LS; citation_author=Fiscella K; citation_author=Epstein RM; citation_author=Kravitz RL; citation_journal_title=Med Care; citation_year=2006; citation_volume=44; citation_issue=12; citation_pages=1092-1098; " /><meta name="citation_fulltext_world_readable" content="" /><meta name="citation_pdf_url" content="https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/2472948/ioi150093.pdf" /> <meta name="citation_xml_url" content="https://datafeed.jamanetwork.com/journals/jamainternalmedicine/xml/2472948" /> <title>Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial | Radiology | JAMA Internal Medicine | JAMA Network</title> <meta name="description" content="This randomized clinical trial evaluates the effectiveness of a standardized patient–based intervention designed to enhance primary care physician"> <link rel="canonical" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472948" /> <script src="//cdn.jamanetwork.com/UI/app/dist/head.min.js?v=638677764511843155"></script> <script src="https://r451.jamanetwork.com/script.js" defer></script> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_HeaderScript"> <meta class="SCM-SharedWidgets-AsyncHeaderAdLoader" data-url="/AMA/AdTag/AMA_AdTag_HeaderScript" data-params="{"parameters":{"siteName":"jamainternalmedicine","siteId":15,"journalId":71,"adDisplay":0,"adSection":"scholarly","adPosition":"","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"> </div> </head> <body data-sitename="jamainternalmedicine" class="pg_article " data-thm="intem"> <script> var App = App || {}; App.suppressAds = App.suppressAds || !!document.getElementsByClassName('suppress-ads').length; App.suppressGtm = App.suppressGtm || !!document.getElementsByClassName('suppress-gtm').length; </script> <div id="ad-interstitial" class="ad-interstitial"> <script defer> googletag.cmd.push(function() { if (App.suppressAds) { return; } // Define a web interstitial ad slot. let interstitialSlot = googletag.defineOutOfPageSlot( App.Ads.adPath + '/scholarly', googletag.enums.OutOfPageFormat.INTERSTITIAL, ); if (interstitialSlot) { App.Ads.slots[13] = interstitialSlot; // Enable optional interstitial triggers and register the slot. interstitialSlot .setTargeting('pos', ['interstitial']) .addService(googletag.pubads()) .setConfig({ interstitial: { triggers: { navBar: true, unhideWindow: true, }, }, }); googletag.display(interstitialSlot); googletag.pubads().refresh([interstitialSlot], { changeCorrelator: false }); googletag.enableServices(); } }); </script> </div> <a class="accessible js-skip-to-navigation" href="#skip-to-navigation">[Skip to Navigation]</a> <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-WNKSNP" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-WNKSNP');</script> <span class="hide tagmanagervalue" data-attribute="productName" data-value="JAMA Internal Medicine" data-type="string"></span> <form method="post" action="./2472948" id="webform" class="m0"> <div class="aspNetHidden"> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="w9cESXxytwZufxwYXUYNvRIaMaHZV108/VlMSw8ShS40ChVSW167rC2Z+urJGBooEHPfL6cEUjQacRtHI/W4fqvXsuI=" /> </div> <div class="aspNetHidden"> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="2173C2F0" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="zpT/motlC/sjy1TsE9dzOSzFlcWLW5OO/epPfbeu+yBVbuMzYaG81rIHudMFJe+8cDidfWD2F1jgxLRHaET1uHJqqb4zYwWi/jWuaQ2WtYNX+EN1ydDlvtvjUuIBsdoGDSfr9WlKj2Tq/+zsyOfhiuSqIpg9uoqcOnRNxOoSiIMu8nNBKhDb3bHw14MaxU0bme8eotpGYUtn5jR5AFSVH0G5ojalA8EPKzzq2Ck2gi7xcPQM9is1ic8sPtYVx7ESsZjibRfV4f3cLaQws8mAx09gx0zf0PNTfkfrmnHp1cVVWh2rCGwKre6v6QnjnIMH1miNFwHko4rx994qgWLr68Ph84qg8/EWH3guUyKHhcD5pBX3JmvsfGQ8ycaotX0LihScxs6l+ZqSNpa5C6ISr0rBl0xjt3qDHDOQBbu+pRE+q8ZTe6rKHA6vqqQ18TS7tXoeJ2MFio8SRbb2WoYIPbqL1ZEhulJcXLJh93v03LzTF7TGgMKJ+WOIh2fCb/aVYpBTecCCHufjGdjQ14f6MNsv+RJoUkYy68xIr2TK8ngF2djdu32Q8rvueTup5uVJNphWsO8twRfX6A7QfgozLqzA11Pr4DMCJRLCQP9vF+IXBgrLxxrWqyRh04VW7V0BHXaBAwp/LbuGnnrDv8iFphj7Wmw=" /> </div> <input id="hdnSiteID" type="hidden" value="15" /> <input id="hdnDomain" type="hidden" value=".jamanetwork.com" /> <section class="master-header"> <script type='text/javascript'> var App = App || {}; App.LoginUserInfo = { isInstLoggedIn: [0], currentSessionId: 'ls0fbtyufg3kk1uxsm5hoenw' }; </script> <input name="ctl00$ctl00$BodyContent$Header$hfGlobalSearchSiteURL" type="hidden" id="hfGlobalSearchSiteURL" value="https://jamanetwork.com/" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsPaidUser" type="hidden" id="hfAppIsPaidUser" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsMember" type="hidden" id="hfAppIsMember" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppSubscribedTo" type="hidden" id="hfAppSubscribedTo" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsIndividual" type="hidden" id="hfAppIsIndividual" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppHasAccess" type="hidden" id="hfAppHasAccess" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsReferredFromGoogle" type="hidden" id="hfAppIsReferredFromGoogle" value="False" /> <input name="ctl00$ctl00$BodyContent$Header$hfSolrAutoSuggestMinimumCharactersLength" type="hidden" id="hfSolrAutoSuggestMinimumCharactersLength" value="2" /> <input name="ctl00$ctl00$BodyContent$Header$hfSolrJournalName" type="hidden" id="hfSolrJournalName" value="JAMA Internal Medicine" /> <input name="ctl00$ctl00$BodyContent$Header$hfSolrJournalID" type="hidden" id="hfSolrJournalID" value="J71" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsLucy" type="hidden" id="hfAppIsLucy" value="false" /> <div class="header-wrap"> <header class="header"> <div class="widget-GdprCookieBanner widget-instance-GdprCookieBanner"> <div class="gdpr-cookie-wrapper js-gdpr-banner"> <div class="gdpr-cookie-body"> Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our <a href="https://jamanetwork.com/pages/privacy-policy#cookies">Cookie Policy</a> <span class="pipe">|</span> <a href="javascript:;" class="js-gdpr-cookie-acceptLink at-acceptgdpr">Continue</a> </div> <input id="hdnDomain" type="hidden" value=".jamanetwork.com" /> <input id="hdnDomainGdpr" type="hidden" value=".jamanetwork.com" /> <input id="hdnClientIdGdpr" type="hidden" value="3" /> </div> </div> <div class="network-bar"> <a class="jama-network" href="/" title="JAMA Network Home"> <img alt="JAMA Network Home" class="title-image" width="443" height="52" src="//cdn.jamanetwork.com/UI/app/svg/Jama_Network_Logo.svg"> </a> </div> <a class="nav-toggler" href="#nav"> <div class="nav-toggler-indicator"> <span class="indicator-stroke"></span> <span class="indicator-stroke"></span> <span class="indicator-stroke"></span> <span class="indicator-stroke"></span> </div> <div class="nav-toggler-site"> <span id="BodyContent_Header_siteFullNamenav" class="nav-toggler-microsite"><span class='network'>JAMA</span> Internal Medicine</span> </div> </a> <nav id="nav" class="nav hide" > <div class="nav-journal-level sb-nav-journal-level"> <a href="https://jamanetwork.com/journals/jamainternalmedicine" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_0" class="home">Home</a><a href="https://jamanetwork.com/journals/jamainternalmedicine/newonline" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_1" class="new-online">New Online</a><a href="https://jamanetwork.com/journals/jamainternalmedicine/currentissue" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_2" class="current-issue">Current Issue</a><a href="https://jamanetwork.com/journals/jamainternalmedicine/pages/for-authors" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_3" class="for-authors">For Authors</a> </div> <div class="nav-journals"> <div class="widget-SelfServeContent widget-instance-HamburgerPublicationMenu"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="HamburgerPublicationMenu" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .nav-journals {margin-bottom: 1em;} .nav-heading {color: #B9B9B9;border-bottom: 0;border-top: 1px solid #242424;font-size: 1.15em;font-weight: 400;margin: 0;padding: .7em .75em .25em;text-transform: uppercase;} a.no-bullet:before {content:none !important;} .nav-heading {font-size: 1.15em;margin-bottom:0;padding-left: 38px;} /* .nav-journals a.theme-jama {background-color: #242424;border-bottom: 1px solid #fff;border-top: 1px solid #fff;color: #fff;font-size: 1.15em;margin-bottom: 8px;padding: 11px 0 9px 37px;} .nav-journals a.theme-jama::before {background: unset;content: "\e91b";display: none;font-family: ama_icons !important;font-size: 1.25em;line-height: 1;} .nav-journals a.theme-jama-network-open {border-bottom:0;} */ .nav .widget-instance-HamburgerPublicationMenu a {padding-left: 36px;} .fake-ribbon {border-left: 8px solid #006e96;} .fake-ribbon a:before {content:none;} .nav .widget-instance-HamburgerPublicationMenu .fake-ribbon a {padding-left:30px;} .nav-journals a.theme-plus:before {background:#d71635;} .nav-journals a.theme-jama-network-open {border-bottom:0;} </style> <div class="fake-ribbon"><a href="/journals/jamainternalmedicine/pages/jama-internal-medicine-author-interviews">Podcast</a></div> <h2 class="nav-heading">JAMA+</h2> <a href="/channels/ai" class="theme-plus">AI</a> <h2 class="nav-heading">Journals</h2> <a href="/journals/jama" class="theme-jama">JAMA</a> <a href="/journals/jamanetworkopen" class="theme-jama-network-open">JAMA Network Open</a> <a href="/journals/jamacardiology" class="theme-jama-cardiology">JAMA Cardiology</a> <a href="/journals/jamadermatology" class="theme-jama-dermatology">JAMA Dermatology</a> <a href="/journals/jama-health-forum" class="theme-jama-health-forum">JAMA Health Forum</a> <a href="/journals/jamainternalmedicine" class="theme-jama-internal-medicine">JAMA Internal Medicine</a> <a href="/journals/jamaneurology" class="theme-jama-neurology">JAMA Neurology</a> <a href="/journals/jamaoncology" class="theme-jama-oncology">JAMA Oncology</a> <a href="/journals/jamaophthalmology" class="theme-jama-ophthalmology">JAMA Ophthalmology </a> <a href="/journals/jamaotolaryngology" class="theme-jama-otolaryngology-head-neck-surgery">JAMA Otolaryngology–Head & Neck Surgery</a> <a href="/journals/jamapediatrics" class="theme-jama-pediatrics">JAMA Pediatrics</a> <a href="/journals/jamapsychiatry" class="theme-jama-psychiatry">JAMA Psychiatry</a> <a href="/journals/jamasurgery" class="theme-jama-surgery">JAMA Surgery</a> <a href="/journals/archneurpsyc" class="theme-archives-of-neurology-psychiatry-1919-1959-">Archives of Neurology & Psychiatry (1919-1959)</a> </div> </div> </div> <div class="nav-network-other"> <a href="https://edhub.ama-assn.org/jn-learning" id="BodyContent_Header_rptOtherResources_aItemResourceList_0" class="is-b link-jn-learning-cme" target="_blank">JN Learning / CME</a><a href="https://store.jamanetwork.com/index.aspx?productcode=56" id="BodyContent_Header_rptOtherResources_aItemResourceList_1" class="is-b link-subscribe" target="_blank">Subscribe</a><a href="https://careers.jamanetwork.com/" id="BodyContent_Header_rptOtherResources_aItemResourceList_2" class="is-b link-jobs" target="_blank">Jobs</a><a href="https://jamanetwork.com/pages/resources-for-librarians" id="BodyContent_Header_rptOtherResources_aItemResourceList_3" class="is-b link-institutions-librarians">Institutions / Librarians</a><a href="https://jamanetwork.com/pages/reprints-and-permissions" id="BodyContent_Header_rptOtherResources_aItemResourceList_4" class="is-b link-reprints-permissions" rel="nofollow">Reprints & Permissions</a> </div> <div class="white text-xxs"> <div class="p05 ml4 mr3 mb1 mt10 flex hamburger-menu-legal"> <a href="/pages/conditions-of-use" class="p0" rel="nofollow">Terms of Use</a> <span class="pl1 pr1">| </span> <a href="/pages/privacy-policy" class="p0" rel="nofollow">Privacy Policy</a> <span class="pl1 pr1">| </span> <a href="/pages/accessibility-statement" class="p0" rel="nofollow">Accessibility Statement</a> </div> <div class="ta-c"> <span class="pb1">2024 American Medical Association. All Rights Reserved</span> </div> </div> </nav> <a class="toolbar-search-trigger is-b" data-mobile-tog-target=".site-search"></a> <div id="site-search" role="search" class="site-search"> <div class="site-search-bar"> <div role="search"> <select name="ctl00$ctl00$BodyContent$Header$ddlForSearch" id="BodyContent_Header_ddlForSearch" Name="dropDownList" class="cs-select cs-skin-border" title="Search Site Selector" role="options" aria-labelledby="searchLabel"> <option value="J*">Search All</option> <option value="3">JAMA</option> <option value="214">JAMA Network Open</option> <option value="192">JAMA Cardiology</option> <option value="12">JAMA Dermatology</option> <option value="261">JAMA Forum Archive</option> <option value="193">JAMA Health Forum</option> <option value="15">JAMA Internal Medicine</option> <option value="16">JAMA Neurology</option> <option value="159">JAMA Oncology</option> <option value="17">JAMA Ophthalmology</option> <option value="18">JAMA Otolaryngology–Head & Neck Surgery</option> <option value="19">JAMA Pediatrics</option> <option value="14">JAMA Psychiatry</option> <option value="20">JAMA Surgery</option> <option value="23">Archives of Neurology & Psychiatry</option> </select> </div> <div class="search-input-container"> <input type="search" name="textbox" autocomplete="off" role="textbox" id="search-term" aria-labelledby="searchLabel" class="search-term at-microsite-search-term" placeholder="Enter Search Term" maxlength="255" title="Enter Search Term"> <ul id="umbrellaSiteAutoCompleteResults" class="term-list hidden"></ul> <label style="display:none" for="umbrellaSiteSearchInputHint" id="searchLabel">Input Search Term</label> <input class="searchTerm search-input" name="textbox" role="textbox" type="text" id="umbrellaSiteSearchInputHint" aria-labelledby="searchLabel" title="Input Search Term" autocomplete="off"> </div>  <a name="button" role="button" class="search-button is-b js-search-button" alt="search button" href="/searchresults"></a> </div> </div> <div id="BodyContent_Header_GlobalSignIn_auth" class="auth"> <a class="auth--trigger is-b is-a" href="javascript:;"> <span id="BodyContent_Header_GlobalSignIn_spnUserFullName" class="user-full-name">Sign In</span> </a> <div class="auth--dropdown js-signIn-dropdown"> <div class="auth--option auth--ind"> <div id="BodyContent_Header_GlobalSignIn_divUserFullName" class="auth--ind-user"></div> <div id="BodyContent_Header_GlobalSignIn_divIndSignIn" class="auth--ind-auth"> <div class="auth--title">Individual Sign In</div> <a href="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948" id="BodyContent_Header_GlobalSignIn_oauthSignInLink" rel="nofollow" class="auth--ind-sign-in">Sign in</a><a href="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948" id="BodyContent_Header_GlobalSignIn_oauthSignUpLink" rel="nofollow" class="auth--ind-create">Create an Account</a> </div> </div> <div id="BodyContent_Header_GlobalSignIn_divInstSignIn" class="auth--option auth--inst"> <div class="auth--inst-auth"> <div class="auth--title">Access through your institution</div> <a href="/signinshibboleth?returnUrl=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948" id="BodyContent_Header_GlobalSignIn_institutionSignIn" rel="nofollow" class="auth--shib">Sign In</a> </div> </div> <div id="BodyContent_Header_GlobalSignIn_divPurchaseOptions" class="auth--option auth--purchase"> <div class="auth--title">Purchase Options:</div> <a id="BodyContent_Header_GlobalSignIn_lnkSubscribeJournal" class="auth--subscribe" rel="nofollow" href="https://store.jamanetwork.com/index.aspx?productcode=56">Subscribe to the JAMA Internal Medicine journal</a> </div> </div> </div> </header> </div> <div class="editors-choice-header"> </div> <div id="BodyContent_Header_divAds" class="header-ad-wrap sb-background-primary-dark"> <div class="leader-ad desktop-only"> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_LeaderboardAd"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_LeaderboardAd" data-params="{"parameters":{"siteName":"jamainternalmedicine","siteId":15,"journalId":71,"adDisplay":1,"adSection":"scholarly","adPosition":"atf","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> </div>  </section> <section class="master-main"> <div class="social-share hide" data-share-journal="JAMAInternalMed" data-share-title="Patient-Centered Counseling and Low-Value Diagnostic Tests"></div> <div class="widget-UserContentAccessWrite widget-instance-AMA_LocalStorage_Article"> <div class="SCM-SharedWidgets-LocalStorage-UserContentAccessWrite" data-values='{"id":"2472948","type":"Article","date":"11/28/2024 1:35:20 AM"}'></div> </div> <div class="widget-ArticleToggleView widget-instance-AMA_ArticleToggleView"> <div class="widget-ArticleFullView widget-instance-AMA_ArticleFullView"> <script> (function () { var bodyElem = document.querySelector('body'); var className = 'split-screen'; if (bodyElem.classList) { bodyElem.classList.add(className); } else { el.className += ' ' + className; } })(); </script> <div id="resources-panel" class="resources-panel"> <span class="hide tagmanagervalue" data-attribute="template" data-value="splitscreen" data-type="string"></span> <div class="tab-nav"> <a class="tab-nav-trigger tab-nav-full-text tablet-down" href="#full-text-tab"> <i class="icon-full_text"><span class="sr-t">full text icon</span></i> <div class="tab-nav-tab-name">Full Text</div> </a> <a class="tab-nav-trigger tab-nav-contents target-tab-active" href="#contents-tab"> <i class="icon-contents"><span class="sr-t">contents icon</span></i> <div class="tab-nav-tab-name">Contents</div> </a> <a class="tab-nav-trigger tab-nav-figure-table" href="#figure-table-tab"> <i class="icon-figures"><span class="sr-t">figure icon</span></i> <div class="tab-nav-tab-name">Figures / <br> Tables</div> </a> <a class="tab-nav-trigger tab-nav-multimedia" href="#multimedia-tab"> <i class="icon-multimedia"><span class="sr-t">multimedia icon</span></i> <div class="tab-nav-tab-name">Multimedia</div> </a> <a class="tab-nav-trigger tab-nav-supplemental" href="#supplemental-tab"> <i class="icon-attach"><span class="sr-t">attach icon</span></i> <div class="tab-nav-tab-name">Supplemental <br> Content</div> </a> <a class="tab-nav-trigger tab-nav-references" href="#references-tab"> <i class="icon-references"><span class="sr-t">references icon</span></i> <div class="tab-nav-tab-name">References</div> </a> <a class="tab-nav-trigger tab-nav-related" href="#related-tab"> <i class="icon-related"><span class="sr-t">related icon</span></i> <div class="tab-nav-tab-name">Related</div> </a> <a class="tab-nav-trigger tab-nav-comments" href="#comments-tab"> <i class="icon-user-comments"><span class="sr-t">comments icon</span></i> <div class="tab-nav-tab-name">Comments</div> </a> </div> <div class="resource-tabs"> <div id="contents-tab" class="resource-tab js-resource-tab contents-tab tab-active"> <div class="contents-tab-contents"> <a id="pdf-link" href="/journals/jamainternalmedicine/articlepdf/2472948/ioi150093.pdf" class="toolbar-tool toolbar-pdf al-link pdfaccess js-pdfaccess" data-article-id="2472948" data-article-url="/journals/jamainternalmedicine/articlepdf/2472948/ioi150093.pdf" data-ajax-url="/Content/CheckPdfAccess"><span class="toolbar-pdf-text"><span class="toolbar-link-text-extra">Download </span><span class="toolbar-link-text">PDF</span></span> </a> <div class="widget-ArticleJumpLinks widget-instance-AMA_ArticleJumpLinks_Widget"> <a href="#top" class="section-jump-link contents-tab-jump-link top-of-article" data-tab-toggle=".tab-nav-full-text">Top of Article</a> <ul class="section-jump-links bullet ml2 pl1"> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616537" data-tab-toggle=".tab-nav-full-text">Abstract</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616542" data-tab-toggle=".tab-nav-full-text">Introduction</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616548" data-tab-toggle=".tab-nav-full-text">Methods</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616576" data-tab-toggle=".tab-nav-full-text">Results</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616586" data-tab-toggle=".tab-nav-full-text">Discussion</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616593" data-tab-toggle=".tab-nav-full-text">Conclusions</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616595" data-tab-toggle=".tab-nav-full-text">Article Information</a></li> <li><a class="section-jump-link contents-tab-jump-link scroll-to head-1" href="#115616596" data-tab-toggle=".tab-nav-full-text">References</a></li> </ul> </div> <div class="widget-SelfServeContent widget-instance-AMA_Contents_Tab_SelfServe"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="v2_article_content_tab" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="bc_right_rail_article_promo"></div> </div> </div> </div> <div class="contents-tab-ad"> <div id="split-screen-contab"></div> </div> </div> <div id="figure-table-tab" class="resource-tab js-resource-tab figure-table-tab need-jobs-ad"> <div class="widget-ArticleFiguresAndTables widget-instance-AMA_Article_Figures_Tab"> <div class="figure-table-wrapper thm-bd-top"><div class="figure-label">Figure 1. Flow Diagram of Primary Care Resident Physician Enrollment and Allocation</div><a id="ioi150093f1" class="figure-table-anchor"> </a><div class="figure-table-links right"><a class="view-large figure-table-link is-b desktop-only" path-from-xml="ioi150093f1" href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f1.png?Expires=1735233641&Signature=Nm1k~Ii1Fd8M2rtsBhPKFTCb3ZrdUequ9CRNFWMW-6C2i0CbUHIjMH-xw-ae00cWFzVTGKYJhs9DYe~yUAd~NK-KGCX131J7AFbEiZiWOcKzdqxRvxVqx81ZcjcSSBwjY7AakLOKpeFNg9-hX78ueZNKWhlLYFPw6nDhkTY4lW8M9umSpZ3v17-g3N7jK8ee0zlFjKYadI5AfCv0W6~0RigXwtF5MBjbfzidrmMVcqJtWyi~7qyMi1kQWE0R31nB0nEViWAPASUMAdQWigGiVWKZs-rP23SNkBIb103-2hTlu7w01ZWFz1Ga0mnf1BzymZ13cUrOgyieqhUwoON3UQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" rel="nofollow"><span class="view-large-text">View Large</span></a><a class="download-ppt figure-table-link is-b stats-download-figure-table" path-from-xml="ioi150093f1" href="/downloadimage.aspx?image=https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f1.png?Expires=1735233641&Signature=Nm1k~Ii1Fd8M2rtsBhPKFTCb3ZrdUequ9CRNFWMW-6C2i0CbUHIjMH-xw-ae00cWFzVTGKYJhs9DYe~yUAd~NK-KGCX131J7AFbEiZiWOcKzdqxRvxVqx81ZcjcSSBwjY7AakLOKpeFNg9-hX78ueZNKWhlLYFPw6nDhkTY4lW8M9umSpZ3v17-g3N7jK8ee0zlFjKYadI5AfCv0W6~0RigXwtF5MBjbfzidrmMVcqJtWyi~7qyMi1kQWE0R31nB0nEViWAPASUMAdQWigGiVWKZs-rP23SNkBIb103-2hTlu7w01ZWFz1Ga0mnf1BzymZ13cUrOgyieqhUwoON3UQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA&sec=115616578&ar=2472948&imagename=&siteId=15" rel="nofollow"><span class="download-ppt-text">Download</span></a><a class="figure-table-twitter figure-table-link figure-table-social addthis_button_twitter is-b" rel="nofollow"><span class="share-text"> </span></a><a class="figure-table-facebook figure-table-link figure-table-social addthis_button_facebook is-b" rel="nofollow"><span class="share-text"> </span></a></div><div class="figure-table cf cb"><div class="figure-table-image"><a href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f1.png?Expires=1735233641&Signature=Nm1k~Ii1Fd8M2rtsBhPKFTCb3ZrdUequ9CRNFWMW-6C2i0CbUHIjMH-xw-ae00cWFzVTGKYJhs9DYe~yUAd~NK-KGCX131J7AFbEiZiWOcKzdqxRvxVqx81ZcjcSSBwjY7AakLOKpeFNg9-hX78ueZNKWhlLYFPw6nDhkTY4lW8M9umSpZ3v17-g3N7jK8ee0zlFjKYadI5AfCv0W6~0RigXwtF5MBjbfzidrmMVcqJtWyi~7qyMi1kQWE0R31nB0nEViWAPASUMAdQWigGiVWKZs-rP23SNkBIb103-2hTlu7w01ZWFz1Ga0mnf1BzymZ13cUrOgyieqhUwoON3UQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ioi150093f1" rel="nofollow"><img data-original="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/m_ioi150093f1.png?Expires=1735233641&Signature=hrmOgTWfMBntGULRgvb7IDLcKRhbp4clu0~b8Cd0RgUWqUdhcogNQ3-OgO9urscx8S8wl2KhKqAJX2kWCGVvT8YUeAHEJwPBCozG4VnwTmjyKlZ0vmfxer7L8fdfLDRTGjuznuKEsXO~rDgSWnfJuw-VdH44QvCx-v6yQIp1EAS3QwZPMHRTCWasZpUnZ4EPC5zBJYctbNTiMN1NwDVscflNAQ4~Qg4WoN-N7YLYX6tcbBTngjpKsH4ljKkFiynyfJZmreR9DJoXjn7QYvrFAW2CTEPr2f38BB3Fo8pwEW-8c6l6kIi1p4mC-QCoWMil9yBnM4sPrMAb6X0Df89Q1w__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="Flow Diagram of Primary Care Resident Physician Enrollment and Allocation" class="content-img lazy" path-from-xml="ioi150093f1" /></a></div></div><div class="figure-caption clip-last-child"></div></div><div class="figure-table-wrapper thm-bd-top"><div class="figure-label">Figure 2. Adjusted Probability of Requested Test Ordering By Study Group and Specific Test</div><a id="ioi150093f2" class="figure-table-anchor"> </a><div class="figure-table-links right"><a class="view-large figure-table-link is-b desktop-only" path-from-xml="ioi150093f2" href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f2.png?Expires=1735233641&Signature=BUZr6CCAkuEGQyvUxTD2rcGBRyWpOpfQASaKIT81ztwNIRmhal8B3jMp8MIaHVHNabmY-OKl8WurP9XvfR-gw7bQa2fmlSOIxsqBO6ylQy2NI2dSKorm2WwXdITwHMckVx8ESdApgABN-VvVeON2wci84GqxoASjwM1BtlC2QtqnS4Fn1Jxu1SMpb4toQ0NBDIwSwVGkiozhXweAePXOoJsujA5W8z1jhNbyqWPUth8-jJUGtUG7FyLEWF7o-4g-wBxUJ5HlMK03d6Shql7Pk8p1m5Yvp7rsr-UZ-oXo83fAEBoOHf2pTTq5s-7wDsbLQN~n6AoA2I2vRWWQE7C3Bg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" rel="nofollow"><span class="view-large-text">View Large</span></a><a class="download-ppt figure-table-link is-b stats-download-figure-table" path-from-xml="ioi150093f2" href="/downloadimage.aspx?image=https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f2.png?Expires=1735233641&Signature=BUZr6CCAkuEGQyvUxTD2rcGBRyWpOpfQASaKIT81ztwNIRmhal8B3jMp8MIaHVHNabmY-OKl8WurP9XvfR-gw7bQa2fmlSOIxsqBO6ylQy2NI2dSKorm2WwXdITwHMckVx8ESdApgABN-VvVeON2wci84GqxoASjwM1BtlC2QtqnS4Fn1Jxu1SMpb4toQ0NBDIwSwVGkiozhXweAePXOoJsujA5W8z1jhNbyqWPUth8-jJUGtUG7FyLEWF7o-4g-wBxUJ5HlMK03d6Shql7Pk8p1m5Yvp7rsr-UZ-oXo83fAEBoOHf2pTTq5s-7wDsbLQN~n6AoA2I2vRWWQE7C3Bg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA&sec=115616582&ar=2472948&imagename=&siteId=15" rel="nofollow"><span class="download-ppt-text">Download</span></a><a class="figure-table-twitter figure-table-link figure-table-social addthis_button_twitter is-b" rel="nofollow"><span class="share-text"> </span></a><a class="figure-table-facebook figure-table-link figure-table-social addthis_button_facebook is-b" rel="nofollow"><span class="share-text"> </span></a></div><div class="figure-table cf cb"><div class="figure-table-image"><a href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093f2.png?Expires=1735233641&Signature=BUZr6CCAkuEGQyvUxTD2rcGBRyWpOpfQASaKIT81ztwNIRmhal8B3jMp8MIaHVHNabmY-OKl8WurP9XvfR-gw7bQa2fmlSOIxsqBO6ylQy2NI2dSKorm2WwXdITwHMckVx8ESdApgABN-VvVeON2wci84GqxoASjwM1BtlC2QtqnS4Fn1Jxu1SMpb4toQ0NBDIwSwVGkiozhXweAePXOoJsujA5W8z1jhNbyqWPUth8-jJUGtUG7FyLEWF7o-4g-wBxUJ5HlMK03d6Shql7Pk8p1m5Yvp7rsr-UZ-oXo83fAEBoOHf2pTTq5s-7wDsbLQN~n6AoA2I2vRWWQE7C3Bg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ioi150093f2" rel="nofollow"><img data-original="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/m_ioi150093f2.png?Expires=1735233641&Signature=GNQZZ-UDk8yzhD3pYIZum4qEDiZoBa5lKTe45sa~ODj7IBL5iqyMJsHkfuch5lzrzFIf91Vy~dJ8xR-YMraJsqE5gBtCz-RM8E0b6PMGxDsrnzoMReqAADCcA5sK8M-Z7VGU1AmDvB-DfP7PogRT56XFEqh0CYjve~2LjsCfVKic~NlUBq2SAst50gW~MltUxNnSE2jv5MY~swH3W7lESoVy90RMW6qWykwSXuBEzhfcOczAPLCDNrxomXjGAfFS6GYLD49waxSuIQjLYTfyMl~j28e8FR-rKsWNP4Kd0S7cVJqdWsaWaORtw~R9m-eWM6MiR81StHKpS2M5TzaaeQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="Adjusted Probability of Requested Test Ordering By Study Group and Specific Test" class="content-img lazy" path-from-xml="ioi150093f2" /></a></div></div><div class="figure-caption clip-last-child"><p class="para"> Symbols indicate probability, and error bars, 95% confidence interval.</p><p class="para"></p></div></div> </div> <div class="widget-ArticleFiguresAndTables widget-instance-AMA_Article_Tables_Tab"> <div class="figure-table-wrapper thm-bd-top"><div class="table-label">Table 1. Resident Characteristics by Study Group</div><a class="figure-table-anchor" id="ioi150093t1"> </a><div class="figure-table-links right"><a class="view-large figure-table-link is-b desktop-only" path-from-xml="ioi150093t1" href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t1.png?Expires=1735233641&Signature=pNmpDnpH30L8vqqJxs6~5g5eRs0YdpmWRAuvV6UNDq2RojJjfmpgHtir4CZhJ3Sd3zSwBxkYEfMCiVLKC5ZfIPxS1XWTjpNd43lBndvWnUiD~r-SC12KjAQ1x-Ty25ly1T0Re1rmGwJ9KZgu~4SfB791-K-u2-~maYMK1kv2W7-yg8LVGIDjovHGtODpUTbWr0~iYr7TLS~9Lw0t3A97gQ5-6o76LsjlDS0BqAofCsQngWeWi24Hm-6AyR5Vsqt1lNBmd6aOWcDuSUdmrsP4rPJATvaffcWsg-Y3Kpm8TNANMRY3DP8xVMZv43Oz7rB0mdkZtf0bsVt5osonwt-8Pg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" rel="nofollow"><span class="view-large-text">View Large</span></a><a class="download-ppt figure-table-link is-b stats-download-figure-table" path-from-xml="ioi150093t1" href="/downloadimage.aspx?image=https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t1.png?Expires=1735233641&Signature=pNmpDnpH30L8vqqJxs6~5g5eRs0YdpmWRAuvV6UNDq2RojJjfmpgHtir4CZhJ3Sd3zSwBxkYEfMCiVLKC5ZfIPxS1XWTjpNd43lBndvWnUiD~r-SC12KjAQ1x-Ty25ly1T0Re1rmGwJ9KZgu~4SfB791-K-u2-~maYMK1kv2W7-yg8LVGIDjovHGtODpUTbWr0~iYr7TLS~9Lw0t3A97gQ5-6o76LsjlDS0BqAofCsQngWeWi24Hm-6AyR5Vsqt1lNBmd6aOWcDuSUdmrsP4rPJATvaffcWsg-Y3Kpm8TNANMRY3DP8xVMZv43Oz7rB0mdkZtf0bsVt5osonwt-8Pg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA&sec=115616579&ar=2472948&imagename=&siteId=15" rel="nofollow"><span class="download-ppt-text">Download</span></a><a class="figure-table-twitter figure-table-link figure-table-social addthis_button_twitter is-b" rel="nofollow"><span class="share-text"> </span></a><a class="figure-table-facebook figure-table-link figure-table-social addthis_button_facebook is-b" rel="nofollow"><span class="share-text"> </span></a></div><div class="figure-table cf cb"><div class="figure-table-image"><a href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t1.png?Expires=1735233641&Signature=pNmpDnpH30L8vqqJxs6~5g5eRs0YdpmWRAuvV6UNDq2RojJjfmpgHtir4CZhJ3Sd3zSwBxkYEfMCiVLKC5ZfIPxS1XWTjpNd43lBndvWnUiD~r-SC12KjAQ1x-Ty25ly1T0Re1rmGwJ9KZgu~4SfB791-K-u2-~maYMK1kv2W7-yg8LVGIDjovHGtODpUTbWr0~iYr7TLS~9Lw0t3A97gQ5-6o76LsjlDS0BqAofCsQngWeWi24Hm-6AyR5Vsqt1lNBmd6aOWcDuSUdmrsP4rPJATvaffcWsg-Y3Kpm8TNANMRY3DP8xVMZv43Oz7rB0mdkZtf0bsVt5osonwt-8Pg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ioi150093t1" rel="nofollow"><img data-original="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/m_ioi150093t1.png?Expires=1735233641&Signature=LGB-RA2myqmLBwzQQvFLLnU7~yuanfr3R0y12CzVdV8ODDC5Je3A7-xr4kVPTYdmY8o4m2rAZxQPkFc0dB0mRPVDvXR9zc~Xhas99Pqkw-7GRZ49nhlIXI-zVQatHf1bzQUZ2600Wa3QhMvPjoU40-7eCaA7X1NUnTU1b8c2CCOzWA8~ZRAIwhtbgS1i-7d1siqvLG5dNZeeUxCnSY0RL6YeEtGA3RIkmxuHXv2hKvK6g5K6EwawoCRdujxGe1sAZHVuxuoX2huOxj-lmb0CxD5JPt62PR54-0MsGXRn3J~zAi6b~cGBghptRBEg6v8WqYILBRRXCkVzCgpvAHzhRA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="Resident Characteristics by Study Group" class="content-img lazy" path-from-xml="ioi150093t1" /></a></div></div><div class="table-caption"></div></div><div class="figure-table-wrapper thm-bd-top"><div class="table-label">Table 2. Patient-Centeredness, Use of Targeted Techniques, and Clinician Rating by Study Group</div><a class="figure-table-anchor" id="ioi150093t2"> </a><div class="figure-table-links right"><a class="view-large figure-table-link is-b desktop-only" path-from-xml="ioi150093t2" href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t2.png?Expires=1735233641&Signature=k9XzFXmL63xgnihjxwU~QadKUAuUbXpsL-jg33GaYvlb0nTu0aUR-W1k3H8LsNqwaTVU-baVhTLZyvjmsH2vvgm~sKt8Ysn6HmIiIPQwQX5i5mkyggWYulzwydNJzW0NXRAI9FSbF1kbcTjO0f4fPbccYnAv5gS4VQ0D94VgJmz0X1H1rw6I9HDKJ1hT2-bVjDcC4v7uQvgGQkLtUrJkUztpp7MSUQpy7jp3OikLoeVsCFr53oIi23RfroLvGViGjRuSkjIRjDxQ5HKAPx9wRnE5fAYsiyzU-MDd9vt8iykakh-PaBFmH~M964py2zS48ImusTPuARVsBYkXkxcraw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" rel="nofollow"><span class="view-large-text">View Large</span></a><a class="download-ppt figure-table-link is-b stats-download-figure-table" path-from-xml="ioi150093t2" href="/downloadimage.aspx?image=https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t2.png?Expires=1735233641&Signature=k9XzFXmL63xgnihjxwU~QadKUAuUbXpsL-jg33GaYvlb0nTu0aUR-W1k3H8LsNqwaTVU-baVhTLZyvjmsH2vvgm~sKt8Ysn6HmIiIPQwQX5i5mkyggWYulzwydNJzW0NXRAI9FSbF1kbcTjO0f4fPbccYnAv5gS4VQ0D94VgJmz0X1H1rw6I9HDKJ1hT2-bVjDcC4v7uQvgGQkLtUrJkUztpp7MSUQpy7jp3OikLoeVsCFr53oIi23RfroLvGViGjRuSkjIRjDxQ5HKAPx9wRnE5fAYsiyzU-MDd9vt8iykakh-PaBFmH~M964py2zS48ImusTPuARVsBYkXkxcraw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA&sec=115616584&ar=2472948&imagename=&siteId=15" rel="nofollow"><span class="download-ppt-text">Download</span></a><a class="figure-table-twitter figure-table-link figure-table-social addthis_button_twitter is-b" rel="nofollow"><span class="share-text"> </span></a><a class="figure-table-facebook figure-table-link figure-table-social addthis_button_facebook is-b" rel="nofollow"><span class="share-text"> </span></a></div><div class="figure-table cf cb"><div class="figure-table-image"><a href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t2.png?Expires=1735233641&Signature=k9XzFXmL63xgnihjxwU~QadKUAuUbXpsL-jg33GaYvlb0nTu0aUR-W1k3H8LsNqwaTVU-baVhTLZyvjmsH2vvgm~sKt8Ysn6HmIiIPQwQX5i5mkyggWYulzwydNJzW0NXRAI9FSbF1kbcTjO0f4fPbccYnAv5gS4VQ0D94VgJmz0X1H1rw6I9HDKJ1hT2-bVjDcC4v7uQvgGQkLtUrJkUztpp7MSUQpy7jp3OikLoeVsCFr53oIi23RfroLvGViGjRuSkjIRjDxQ5HKAPx9wRnE5fAYsiyzU-MDd9vt8iykakh-PaBFmH~M964py2zS48ImusTPuARVsBYkXkxcraw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ioi150093t2" rel="nofollow"><img data-original="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/m_ioi150093t2.png?Expires=1735233641&Signature=IB0zNQXy6duGoCjDT79DRRjsVPC2a9RXirjQNhFJ1GielZZsOSji8sG0xsxU8ciBJ29ia22rEAJSkHZjfybGNh8vdPFZ0CNPy25hXJrUPf8H8BMqqpncALXox~nRhkqgvjqa7AryKKKOXn8PQ1-OkzKMUBwnFm7EbUjyXZ8-7FJA8yuOZkfsN7wNnLAWqToFvbK~~2LBjLaMMnNS3IGY7uMOIwgBfTSdz5yTb52sRT4Sqg-evzExdREGrr~0M0k8wTbVTt8Q-cUReKw3dzb~7iSUBM5DIFiRyc34n5TbRqfQWTdYWoo1rx9qi2Fu0xYZaLaOWfH6cRvtg12SvHug0A__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="Patient-Centeredness, Use of Targeted Techniques, and Clinician Rating by Study Group" class="content-img lazy" path-from-xml="ioi150093t2" /></a></div></div><div class="table-caption"></div></div><div class="figure-table-wrapper thm-bd-top"><div class="table-label">Table 3. Diagnostic Testing Among Actual Adult Patients by Preintervention vs Postintervention Period and Study Group </div><a class="figure-table-anchor" id="ioi150093t3"> </a><div class="figure-table-links right"><a class="view-large figure-table-link is-b desktop-only" path-from-xml="ioi150093t3" href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t3.png?Expires=1735233641&Signature=qI87p3Hk8IR~~~kFIqktBE7zc0QmtNh8w72s0oVYMfyKzO-5CRtjTN9uZ1tiSOIGsgiaoCSEiHGh78uKA2HuFH~SabtC4~K3kYn3xO20OLAYwKzu-cPXQKGt0sVCXVsmixI2~BDBeMQFtgWMV0wwGarkiFlArHdPouqrYSOMiijsLmatIhK1YeS7p0GZmf8xYNlTXv5asefluvwMMc-wvZ8-Ys2UaKWGxUDijlPwk8p9rt8d-kx3A~PsN2v-SQzsus9dizFqFbhfm-xcnG0p4sdEPu0qlI9fc4RVVbW7r-hHEFIidLNArF3Cx7c1No3o1NUFvasZlvjlDPS76FjSqg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" rel="nofollow"><span class="view-large-text">View Large</span></a><a class="download-ppt figure-table-link is-b stats-download-figure-table" path-from-xml="ioi150093t3" href="/downloadimage.aspx?image=https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t3.png?Expires=1735233641&Signature=qI87p3Hk8IR~~~kFIqktBE7zc0QmtNh8w72s0oVYMfyKzO-5CRtjTN9uZ1tiSOIGsgiaoCSEiHGh78uKA2HuFH~SabtC4~K3kYn3xO20OLAYwKzu-cPXQKGt0sVCXVsmixI2~BDBeMQFtgWMV0wwGarkiFlArHdPouqrYSOMiijsLmatIhK1YeS7p0GZmf8xYNlTXv5asefluvwMMc-wvZ8-Ys2UaKWGxUDijlPwk8p9rt8d-kx3A~PsN2v-SQzsus9dizFqFbhfm-xcnG0p4sdEPu0qlI9fc4RVVbW7r-hHEFIidLNArF3Cx7c1No3o1NUFvasZlvjlDPS76FjSqg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA&sec=115616585&ar=2472948&imagename=&siteId=15" rel="nofollow"><span class="download-ppt-text">Download</span></a><a class="figure-table-twitter figure-table-link figure-table-social addthis_button_twitter is-b" rel="nofollow"><span class="share-text"> </span></a><a class="figure-table-facebook figure-table-link figure-table-social addthis_button_facebook is-b" rel="nofollow"><span class="share-text"> </span></a></div><div class="figure-table cf cb"><div class="figure-table-image"><a href="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/ioi150093t3.png?Expires=1735233641&Signature=qI87p3Hk8IR~~~kFIqktBE7zc0QmtNh8w72s0oVYMfyKzO-5CRtjTN9uZ1tiSOIGsgiaoCSEiHGh78uKA2HuFH~SabtC4~K3kYn3xO20OLAYwKzu-cPXQKGt0sVCXVsmixI2~BDBeMQFtgWMV0wwGarkiFlArHdPouqrYSOMiijsLmatIhK1YeS7p0GZmf8xYNlTXv5asefluvwMMc-wvZ8-Ys2UaKWGxUDijlPwk8p9rt8d-kx3A~PsN2v-SQzsus9dizFqFbhfm-xcnG0p4sdEPu0qlI9fc4RVVbW7r-hHEFIidLNArF3Cx7c1No3o1NUFvasZlvjlDPS76FjSqg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ioi150093t3" rel="nofollow"><img data-original="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/934910/m_ioi150093t3.png?Expires=1735233641&Signature=P2KbqQrry1LK9XAqvHzroSRN-ZN-EslNRnq7jjzdCF3hdvBEDWzMDSex1CxTlwceeTWMvVxVKrQ99-HB57SXPkiYVt60o3zD6ximqf1oZfTaWJRydhswW5ylZ-4XWAfpEVcZY-2DSQv-uPRth4bKOX19L~EkVoMpIMXF4GuyhETG2H9gm5RSf0877e-fpbca2XHl8DLKDn0InIy7coLf~rtm8MJ74IOvaedL2XpfyavXkGaQwAjbsrJ0vwFdZXvLTTSAXFSiN9ga~TwuH7ApVqXD1~DQDGuyPW6EhsxUSRntchKLiMAgJNAN9ZhfGk-UvvJa7erTg04PIy22ipWOmg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="Diagnostic Testing Among Actual Adult Patients by Preintervention vs Postintervention Period and Study Group " class="content-img lazy" path-from-xml="ioi150093t3" /></a></div></div><div class="table-caption"></div></div> </div> </div> <div id="multimedia-tab" class="resource-tab js-resource-tab multimedia-tab need-jobs-ad"> </div> <div id="supplemental-tab" class="resource-tab js-resource-tab supplemental-tab need-jobs-ad"> </div> <div id="references-tab" class="resource-tab js-resource-tab references-tab need-jobs-ad"> <div class="references-wrap"> <div class="widget-SectionDisplay widget-instance-AMA_References_Tab"> <div class="references"><div class="reference"><a class="reference-number" id="ioi150093r1">1.</a><div class="reference-content">Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. <i xmlns:helper="urn:XsltStringHelper"> Arch Intern Med</i>. 2011;171(15):1385-1390.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/21606090" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=The%20%E2%80%9Ctop%205%E2%80%9D%20lists%20in%20primary%20care%3A%20meeting%20the%20responsibility%20of%20professionalism.&publication_year=2011&journal=Arch%20Intern%20Med&volume=171&pages=1385-1390" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/archinternmed.2011.231" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/archinternmed.2011.231" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r2">2.</a><div class="reference-content">Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. <i xmlns:helper="urn:XsltStringHelper"> JAMA</i>. 2003;289(21):2810-2818.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/12783911" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Rapid%20magnetic%20resonance%20imaging%20vs%20radiographs%20for%20patients%20with%20low%20back%20pain%3A%20a%20randomized%20controlled%20trial.&author=JG%20Jarvik&author=W%20Hollingworth&author=B%20Martin&publication_year=2003&journal=JAMA&volume=289&pages=2810-2818" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/jama.289.21.2810" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/jama.289.21.2810" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r3">3.</a><div class="reference-content">Järvinen TL, Michaëlsson K, Jokihaara J, et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. <i xmlns:helper="urn:XsltStringHelper"> BMJ</i>. 2015;350:h2088.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/26013536" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Overdiagnosis%20of%20bone%20fragility%20in%20the%20quest%20to%20prevent%20hip%20fracture.&author=TL%20Järvinen&author=K%20Michaëlsson&author=J%20Jokihaara&publication_year=2015&journal=BMJ&volume=350&pages=h2088" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1136/bmj.h2088" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1136/bmj.h2088" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r4">4.</a><div class="reference-content">Choosing Wisely: An Initiative of the ABIM Foundation. 2015. <a href="http://www.choosingwisely.org/">http://www.choosingwisely.org/</a>. Accessed July 9, 2015.</div></div><div class="reference"><a class="reference-number" id="ioi150093r5">5.</a><div class="reference-content">Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. <i xmlns:helper="urn:XsltStringHelper"> Patient-Centered Medicine: Transforming the Clinical Method.</i> Abingdon, England: Radcliffe Medical Press Ltd; 2003.</div></div><div class="reference"><a class="reference-number" id="ioi150093r6">6.</a><div class="reference-content">Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “no”: strategies primary care physicians use to deny patient requests. <i xmlns:helper="urn:XsltStringHelper"> Arch Intern Med</i>. 2010;170(4):381-388.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/20177043" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Getting%20to%20%E2%80%9Cno%E2%80%9D%3A%20strategies%20primary%20care%20physicians%20use%20to%20deny%20patient%20requests.&author=DA%20Paterniti&author=TL%20Fancher&author=CS%20Cipri&author=S%20Timmermans&author=J%20Heritage&author=RL%20Kravitz&publication_year=2010&journal=Arch%20Intern%20Med&volume=170&pages=381-388" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/archinternmed.2009.533" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/archinternmed.2009.533" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r7">7.</a><div class="reference-content">Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. <i xmlns:helper="urn:XsltStringHelper"> Ann Fam Med</i>. 2005;3(5):415-421.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/16189057" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Patient-centered%20communication%20and%20diagnostic%20testing.&author=RM%20Epstein&author=P%20Franks&author=CG%20Shields&publication_year=2005&journal=Ann%20Fam%20Med&volume=3&pages=415-421" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1370/afm.348" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1370/afm.348" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r8">8.</a><div class="reference-content">Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. <i xmlns:helper="urn:XsltStringHelper"> Cochrane Database Syst Rev</i>. 2012;12:CD003267.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/23235595" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Interventions%20for%20providers%20to%20promote%20a%20patient-centred%20approach%20in%20clinical%20consultations.&author=F%20Dwamena&author=M%20Holmes-Rovner&author=CM%20Gaulden&publication_year=2012&journal=Cochrane%20Database%20Syst%20Rev&volume=12&pages=CD003267" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a></div></div><div class="reference"><a class="reference-number" id="ioi150093r9">9.</a><div class="reference-content">Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P. Improving physicians’ HIV risk-assessment skills using announced and unannounced standardized patients. <i xmlns:helper="urn:XsltStringHelper"> J Gen Intern Med</i>. 2001;16(3):176-180.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/11318913" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Improving%20physicians%E2%80%99%20HIV%20risk-assessment%20skills%20using%20announced%20and%20unannounced%20standardized%20patients.&author=RM%20Epstein&author=JC%20Levenkron&author=L%20Frarey&author=J%20Thompson&author=K%20Anderson&author=P%20Franks&publication_year=2001&journal=J%20Gen%20Intern%20Med&volume=16&pages=176-180" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1111/j.1525-1497.2001.02299.x" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1111/j.1525-1497.2001.02299.x" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r10">10.</a><div class="reference-content">Jerant A, Kravitz RL, Azari R, et al. Training residents to employ self-efficacy-enhancing interviewing techniques: randomized controlled trial of a standardized patient intervention. <i xmlns:helper="urn:XsltStringHelper"> J Gen Intern Med</i>. 2009;24(5):606-613.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/19296179" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Training%20residents%20to%20employ%20self-efficacy-enhancing%20interviewing%20techniques%3A%20randomized%20controlled%20trial%20of%20a%20standardized%20patient%20intervention.&author=A%20Jerant&author=RL%20Kravitz&author=R%20Azari&publication_year=2009&journal=J%20Gen%20Intern%20Med&volume=24&pages=606-613" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1007/s11606-009-0946-4" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1007/s11606-009-0946-4" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r11">11.</a><div class="reference-content">Epstein RM, Street RL Jr. Shared mind: communication, decision making, and autonomy in serious illness. <i xmlns:helper="urn:XsltStringHelper"> Ann Fam Med</i>. 2011;9(5):454-461.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/21911765" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Shared%20mind%3A%20communication%2C%20decision%20making%2C%20and%20autonomy%20in%20serious%20illness.&author=RM%20Epstein&author=RL%20Street&publication_year=2011&journal=Ann%20Fam%20Med&volume=9&pages=454-461" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1370/afm.1301" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1370/afm.1301" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r12">12.</a><div class="reference-content">Charles C, Whelan T, Gafni A. What do we mean by partnership in making decisions about treatment? <i xmlns:helper="urn:XsltStringHelper"> BMJ</i>. 1999;319(7212):780-782.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/10488014" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=What%20do%20we%20mean%20by%20partnership%20in%20making%20decisions%20about%20treatment%3F&author=C%20Charles&author=T%20Whelan&author=A%20Gafni&publication_year=1999&journal=BMJ&volume=319&pages=780-782" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1136/bmj.319.7212.780" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1136/bmj.319.7212.780" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r13">13.</a><div class="reference-content">Stewart M, Ryan BL. <i xmlns:helper="urn:XsltStringHelper"> Assessing Communication Between Patients and Physicians: The Measure of Patient-Centered Communication (MPCC)</i>. London, Ontario, Canada: Thames Valley Family Practice Research Unit and Centre for Studies in Family Medicine; 2001.</div></div><div class="reference"><a class="reference-number" id="ioi150093r14">14.</a><div class="reference-content">Goertz M, Thorson D, Bonsell J, et al. Adult acute and subacute low back pain<i>.</i> Bloomington, MN: Institute for Clinical Systems Improvement. Updated November 2012. <a href="https://www.icsi.org/_asset/bjvqrj/LBP.pdf">https://www.icsi.org/_asset/bjvqrj/LBP.pdf</a>. Accessed September 7, 2015.</div></div><div class="reference"><a class="reference-number" id="ioi150093r15">15.</a><div class="reference-content">Florence R, Allen S, Benedict L, et al. Diagnosis and treatment of osteoporosis. Bloomington, MN: Institute for Clinical Systems Improvement. Updated July 2013. <a href="https://www.icsi.org/_asset/vnw0c3/Osteo.pdf">https://www.icsi.org/_asset/vnw0c3/Osteo.pdf</a>. Accessed September 7, 2015.</div></div><div class="reference"><a class="reference-number" id="ioi150093r16">16.</a><div class="reference-content">Gerrity MS, DeVellis RF, Earp JA. Physicians’ reactions to uncertainty in patient care: a new measure and new insights. <i xmlns:helper="urn:XsltStringHelper"> Med Care</i>. 1990;28(8):724-736.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/2385142" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Physicians%E2%80%99%20reactions%20to%20uncertainty%20in%20patient%20care%3A%20a%20new%20measure%20and%20new%20insights.&author=MS%20Gerrity&author=RF%20DeVellis&author=JA%20Earp&publication_year=1990&journal=Med%20Care&volume=28&pages=724-736" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1097/00005650-199008000-00005" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1097/00005650-199008000-00005" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r17">17.</a><div class="reference-content">Hade EM, Murray DM, Pennell ML, et al. Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies. <i xmlns:helper="urn:XsltStringHelper"> J Natl Cancer Inst Monogr</i>. 2010;2010(40):97-103.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/20386058" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Intraclass%20correlation%20estimates%20for%20cancer%20screening%20outcomes%3A%20estimates%20and%20applications%20in%20the%20design%20of%20group-randomized%20cancer%20screening%20studies.&author=EM%20Hade&author=DM%20Murray&author=ML%20Pennell&publication_year=2010&journal=J%20Natl%20Cancer%20Inst%20Monogr&volume=2010&pages=97-103" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1093/jncimonographs/lgq011" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1093/jncimonographs/lgq011" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r18">18.</a><div class="reference-content">Solomon DH, Hashimoto H, Daltroy L, Liang MH. Techniques to improve physicians’ use of diagnostic tests: a new conceptual framework. <i xmlns:helper="urn:XsltStringHelper"> JAMA</i>. 1998;280(23):2020-2027.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/9863854" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Techniques%20to%20improve%20physicians%E2%80%99%20use%20of%20diagnostic%20tests%3A%20a%20new%20conceptual%20framework.&author=DH%20Solomon&author=H%20Hashimoto&author=L%20Daltroy&author=MH%20Liang&publication_year=1998&journal=JAMA&volume=280&pages=2020-2027" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/jama.280.23.2020" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/jama.280.23.2020" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r19">19.</a><div class="reference-content">Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. <i xmlns:helper="urn:XsltStringHelper"> Radiology</i>. 2009;251(1):147-155.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/19221058" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Effect%20of%20computerized%20order%20entry%20with%20integrated%20decision%20support%20on%20the%20growth%20of%20outpatient%20procedure%20volumes%3A%20seven-year%20time%20series%20analysis.&author=CL%20Sistrom&author=PA%20Dang&author=JB%20Weilburg&author=KJ%20Dreyer&author=DI%20Rosenthal&author=JH%20Thrall&publication_year=2009&journal=Radiology&volume=251&pages=147-155" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1148/radiol.2511081174" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1148/radiol.2511081174" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r20">20.</a><div class="reference-content">Ip IK, Gershanik EF, Schneider LI, et al. Impact of IT-enabled intervention on MRI use for back pain. <i xmlns:helper="urn:XsltStringHelper"> Am J Med</i>. 2014;127(6):512-518.e1.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/24513065" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Impact%20of%20IT-enabled%20intervention%20on%20MRI%20use%20for%20back%20pain.&author=IK%20Ip&author=EF%20Gershanik&author=LI%20Schneider&publication_year=2014&journal=Am%20J%20Med&volume=127&pages=512-518.e1" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1016/j.amjmed.2014.01.024" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1016/j.amjmed.2014.01.024" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r21">21.</a><div class="reference-content">Martin AR, Wolf MA, Thibodeau LA, Dzau V, Braunwald E. A trial of two strategies to modify the test-ordering behavior of medical residents. <i xmlns:helper="urn:XsltStringHelper"> N Engl J Med</i>. 1980;303(23):1330-1336.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/7432374" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=A%20trial%20of%20two%20strategies%20to%20modify%20the%20test-ordering%20behavior%20of%20medical%20residents.&author=AR%20Martin&author=MA%20Wolf&author=LA%20Thibodeau&author=V%20Dzau&author=E%20Braunwald&publication_year=1980&journal=N%20Engl%20J%20Med&volume=303&pages=1330-1336" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1056/NEJM198012043032304" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1056/NEJM198012043032304" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r22">22.</a><div class="reference-content">Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. <i xmlns:helper="urn:XsltStringHelper"> N Engl J Med</i>. 2010;363(1):4-6.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/20573920" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=The%20uncritical%20use%20of%20high-tech%20medical%20imaging.&author=BJ%20Hillman&author=JC%20Goldsmith&publication_year=2010&journal=N%20Engl%20J%20Med&volume=363&pages=4-6" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1056/NEJMp1003173" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1056/NEJMp1003173" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r23">23.</a><div class="reference-content">Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. <i xmlns:helper="urn:XsltStringHelper"> Ann Intern Med</i>. 2015;162(2):100-108.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/25599349" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Overuse%20of%20testing%20in%20preoperative%20evaluation%20and%20syncope%3A%20a%20survey%20of%20hospitalists.&author=A%20Kachalia&author=A%20Berg&author=A%20Fagerlin&publication_year=2015&journal=Ann%20Intern%20Med&volume=162&pages=100-108" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.7326/M14-0694" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.7326/M14-0694" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r24">24.</a><div class="reference-content">Srinivasan M, Franks P, Meredith LS, Fiscella K, Epstein RM, Kravitz RL. Connoisseurs of care? unannounced standardized patients’ ratings of physicians. <i xmlns:helper="urn:XsltStringHelper"> Med Care</i>. 2006;44(12):1092-1098.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/17122713" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Connoisseurs%20of%20care%3F%20unannounced%20standardized%20patients%E2%80%99%20ratings%20of%20physicians.&author=M%20Srinivasan&author=P%20Franks&author=LS%20Meredith&author=K%20Fiscella&author=RM%20Epstein&author=RL%20Kravitz&publication_year=2006&journal=Med%20Care&volume=44&pages=1092-1098" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1097/01.mlr.0000237197.92152.5e" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1097/01.mlr.0000237197.92152.5e" xmlns:helper="urn:XsltStringHelper"> </span></div></div></div> </div> </div> </div> <div id="related-tab" class="resource-tab js-resource-tab related-tab need-jobs-ad"> <div class="widget-ArticleLinks widget-instance-AMA_See_Also_Related_Content"> <ul class="article-links related-content"> <li class="article-link related-article odd"> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472942" class="td-n"> <div class="related-article-title">Research in Medical Education and Patient-Centered Outcomes</div> <div class="related-journal-name">JAMA Internal Medicine</div> <div class="related-article-type">Editorial</div> <div class="related-article-date">February 1, 2016</div> <div class="related-article-excerpt"></div> <div class="related-article-authors">Patrick G. O’Malley, MD, MPH; Louis N. Pangaro, MD</div> </a> </li> <li class="article-link related-article even"> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472945" class="td-n"> <div class="related-article-title">Patterns of Needlestick and Sharps Injuries Among Training Residents</div> <div class="related-journal-name">JAMA Internal Medicine</div> <div class="related-article-type">Research Letter</div> <div class="related-article-date">February 1, 2016</div> <div class="related-article-excerpt">This observational study analyzes the incidence of needlestick and sharps injuries reported by medical residents between January 2000 and June 2014 trained at a US hospital.</div> <div class="related-article-authors">Thomas Marnejon, DO; David Gemmel, PhD; Kelli Mulhern, BS</div> </a> </li> <li class="article-link related-article odd"> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472946" class="td-n"> <div class="related-article-title">Electronic Audit of an Inpatient Service</div> <div class="related-journal-name">JAMA Internal Medicine</div> <div class="related-article-type">Research Letter</div> <div class="related-article-date">February 1, 2016</div> <div class="related-article-excerpt">This study examines resident behavior on an inpatient general medicine service to describe how trainees use the electronic health record to balance education and patient care.</div> <div class="related-article-authors">David Ouyang, MD; Jonathan H. Chen, MD, PhD; Jason Hom, MD; Jeffrey Chi, MD</div> </a> </li> <li class="article-link related-article even"> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472947" class="td-n"> <div class="related-article-title">Southern Medical Students’ Views on Medicaid Expansion</div> <div class="related-journal-name">JAMA Internal Medicine</div> <div class="related-article-type">Research Letter</div> <div class="related-article-date">February 1, 2016</div> <div class="related-article-excerpt">This cross-sectional study surveys medical students in 8 Southern public medical schools about Medicaid eligibility in their states.</div> <div class="related-article-authors">Esme B. Cullen; Karen E. Hauer, MD, PhD; Leo Eisenstein; Christy K. Boscardin, PhD; Steven A. Schroeder, MD</div> </a> </li> <li class="article-link related-article odd"> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472944" class="td-n"> <div class="related-article-title">Health Policy and Medical Training</div> <div class="related-journal-name">JAMA Internal Medicine</div> <div class="related-article-type">Invited Commentary</div> <div class="related-article-date">February 1, 2016</div> <div class="related-article-excerpt"></div> <div class="related-article-authors">Rachel J. Stern, MD</div> </a> </li> <li class="article-link related-article even"> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472943" class="td-n"> <div class="related-article-title">An Intervention to Reduce Use of Low-Value Imaging Tests</div> <div class="related-journal-name">JAMA Internal Medicine</div> <div class="related-article-type">Editor's Note</div> <div class="related-article-date">February 1, 2016</div> <div class="related-article-excerpt"></div> <div class="related-article-authors">Kenneth E. Covinsky, MD; Rita F. Redberg, MD</div> </a> </li> </ul> </div> <div class="widget-EditorsChoice widget-instance-AMA_EditorsChoice_Links"> <div class="sm-linked-content"> <div class="sm-linked-content--item"> <a href="http://sites.jamanetwork.com/jama-medical-education/index.html" target="_blank" class="sm-linked-content--link fw-b sb-tc"><i class="icon-url d-ib thm-col"></i>2015 JAMA Network Medical Education Website</a> </div> </div> </div> <div class="widget-RelatedTopics widget-instance-AMA_Related_Topics"> <div class="related-topics-block"> <h4 class="related-topics-heading topic-suggestions-heading sb-sc"> See More About </h4> <div class="related-topics topic-suggestions"> <a href="https://jamanetwork.com/collections/42129/radiology" id="item_Link" class="related-topic topic-suggestion no-wrap sb-anchor-light">Radiology</a> <a href="https://jamanetwork.com/collections/5739/medical-education-and-training" id="item_Link_1" class="related-topic topic-suggestion no-wrap sb-anchor-light">Medical Education and Training</a> <a href="https://jamanetwork.com/collections/5668/geriatrics" id="item_Link_2" class="related-topic topic-suggestion no-wrap sb-anchor-light">Geriatrics</a> <a href="https://jamanetwork.com/collections/5810/osteoporosis" id="item_Link_3" class="related-topic topic-suggestion no-wrap sb-anchor-light">Osteoporosis</a> <a href="https://jamanetwork.com/collections/5833/shared-decision-making-and-communication" id="item_Link_4" class="related-topic topic-suggestion no-wrap sb-anchor-light">Shared Decision Making and Communication</a> </div> </div> </div> <div class="ymal--footer"> <div class="widget-WidgetLoader widget-instance-AMA_PersonalizedContent_SplitScreenView_Footer"> <div class="SCM-SharedWidgets-AsyncWidgetLoader" data-url="/Personalization/PersonalizedContent/AMA_PersonalizedContent_SplitScreenView_Footer" data-params="{"parameters":{"resourceIdToExclude":2472948,"resourceTypeToExclude":3},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <hr /> <div class="manage-interest"> <h4><a href="#" class="manage-interests-link-no-access thm-col-sec">Select Your Interests</a></h4> <div class="widget-ManageCollectionInterests widget-instance-ManageCollectionInterests_SplitScreen"> <div class="manage-interests-modal reveal-modal small modal" data-reveal> <div class="manage-interests--header"> <div class="widget-SelfServeContent widget-instance-AMA_ManageInterests_Header"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="AllSitesManageInterestsHeader" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style> h4 { font-size: 20px !important; } </style> <h4>Select Your Interests</h4> <p>Customize your JAMA Network experience by selecting one or more topics from the list below.</p> </div> </div> </div><div class="manage-interests--categories"> <ul class="category-list"> <li><span class="category-list-item " data-categoryid="46425">Academic Medicine</span></li> <li><span class="category-list-item " data-categoryid="5489">Acid Base, Electrolytes, Fluids</span></li> <li><span class="category-list-item " data-categoryid="5504">Allergy and Clinical Immunology</span></li> <li><span class="category-list-item " data-categoryid="46447">American Indian or Alaska Natives</span></li> <li><span class="category-list-item " data-categoryid="5510">Anesthesiology</span></li> <li><span class="category-list-item " data-categoryid="42143">Anticoagulation</span></li> <li><span class="category-list-item " data-categoryid="6261">Art and Images in Psychiatry</span></li> <li><span class="category-list-item " data-categoryid="42097">Assisted Reproduction</span></li> <li><span class="category-list-item " data-categoryid="42099">Bleeding and Transfusion</span></li> <li><span class="category-list-item " data-categoryid="5548">Cardiology</span></li> <li><span class="category-list-item " data-categoryid="44036">Caring for the Critically Ill Patient</span></li> <li><span class="category-list-item " data-categoryid="6255">Challenges in Clinical Electrocardiography</span></li> <li><span class="category-list-item " data-categoryid="46435">Climate and Health</span></li> <li><span class="category-list-item " data-categoryid="46448">Climate Change</span></li> <li><span class="category-list-item " data-categoryid="44038">Clinical Challenge</span></li> <li><span class="category-list-item " data-categoryid="44039">Clinical Implications of Basic Neuroscience</span></li> <li><span class="category-list-item " data-categoryid="5614">Clinical Pharmacy and Pharmacology</span></li> <li><span class="category-list-item " data-categoryid="46499">Coaching</span></li> <li><span class="category-list-item " data-categoryid="5575">Complementary and Alternative Medicine</span></li> <li><span class="category-list-item " data-categoryid="44040">Consensus Statements</span></li> <li><span class="category-list-item " data-categoryid="46099">Coronavirus (COVID-19)</span></li> <li><span class="category-list-item " data-categoryid="5584">Critical Care Medicine</span></li> <li><span class="category-list-item " data-categoryid="46325">Cultural Competency</span></li> <li><span class="category-list-item " data-categoryid="44019">Dental Medicine</span></li> <li><span class="category-list-item " data-categoryid="5598">Dermatology</span></li> <li><span class="category-list-item " data-categoryid="44011">Diabetes and Endocrinology</span></li> <li><span class="category-list-item " data-categoryid="46320">Diagnostic Test Interpretation</span></li> <li><span class="category-list-item " data-categoryid="46498">Digital Health</span></li> <li><span class="category-list-item " data-categoryid="42054">Drug Development</span></li> <li><span class="category-list-item " data-categoryid="5621">Emergency Medicine</span></li> <li><span class="category-list-item " data-categoryid="5819">End of Life, Hospice, Palliative Care</span></li> <li><span class="category-list-item " data-categoryid="42107">Environmental Health</span></li> <li><span class="category-list-item " data-categoryid="46387">Equity, Diversity, and Inclusion</span></li> <li><span class="category-list-item " data-categoryid="42108">Ethics</span></li> <li><span class="category-list-item " data-categoryid="5644">Facial Plastic Surgery</span></li> <li><span class="category-list-item " data-categoryid="44012">Gastroenterology and Hepatology</span></li> <li><span class="category-list-item " data-categoryid="5664">Genetics and Genomics</span></li> <li><span class="category-list-item " data-categoryid="44041">Genomics and Precision Health</span></li> <li><span class="category-list-item " data-categoryid="5668">Geriatrics</span></li> <li><span class="category-list-item " data-categoryid="5670">Global Health</span></li> <li><span class="category-list-item " data-categoryid="46427">Guide to Statistics and Methods</span></li> <li><span class="category-list-item " data-categoryid="5672">Guidelines</span></li> <li><span class="category-list-item " data-categoryid="5674">Hair Disorders</span></li> <li><span class="category-list-item " data-categoryid="42113">Health Care Delivery Models</span></li> <li><span class="category-list-item " data-categoryid="42114">Health Care Economics, Insurance, Payment</span></li> <li><span class="category-list-item " data-categoryid="42116">Health Care Quality</span></li> <li><span class="category-list-item " data-categoryid="5680">Health Care Reform</span></li> <li><span class="category-list-item " data-categoryid="5830">Health Care Safety</span></li> <li><span class="category-list-item " data-categoryid="5682">Health Care Workforce</span></li> <li><span class="category-list-item " data-categoryid="5679">Health Disparities</span></li> <li><span class="category-list-item " data-categoryid="46328">Health Inequities</span></li> <li><span class="category-list-item " data-categoryid="44020">Health Policy</span></li> <li><span class="category-list-item " data-categoryid="46451">Health Systems Science</span></li> <li><span class="category-list-item " data-categoryid="5688">Hematology</span></li> <li><span class="category-list-item " data-categoryid="5692">History of Medicine</span></li> <li><span class="category-list-item " data-categoryid="5514">Humanities</span></li> <li><span class="category-list-item " data-categoryid="5697">Hypertension</span></li> <li><span class="category-list-item " data-categoryid="44043">Images in Neurology</span></li> <li><span class="category-list-item " data-categoryid="45887">Implementation Science</span></li> <li><span class="category-list-item " data-categoryid="5702">Infectious Diseases</span></li> <li><span class="category-list-item " data-categoryid="44044">Innovations in Health Care Delivery</span></li> <li><span class="category-list-item " data-categoryid="46477">JAMA Forum</span></li> <li><span class="category-list-item " data-categoryid="44070">JAMA Infographic</span></li> <li><span class="category-list-item " data-categoryid="5716">Law and Medicine</span></li> <li><span class="category-list-item " data-categoryid="45308">Leading Change</span></li> <li><span class="category-list-item " data-categoryid="44045">Less is More</span></li> <li><span class="category-list-item " data-categoryid="46327">LGBTQIA Medicine</span></li> <li><span class="category-list-item " data-categoryid="5720">Lifestyle Behaviors</span></li> <li><span class="category-list-item " data-categoryid="45311">Medical Coding</span></li> <li><span class="category-list-item " data-categoryid="5738">Medical Devices and Equipment</span></li> <li><span class="category-list-item " data-categoryid="44023">Medical Education</span></li> <li><span class="category-list-item " data-categoryid="5739">Medical Education and Training</span></li> <li><span class="category-list-item " data-categoryid="5713">Medical Journals and Publishing</span></li> <li><span class="category-list-item " data-categoryid="5746">Melanoma</span></li> <li><span class="category-list-item " data-categoryid="5766">Narrative Medicine</span></li> <li><span class="category-list-item " data-categoryid="5769">Nephrology</span></li> <li><span class="category-list-item " data-categoryid="5777">Neurology</span></li> <li><span class="category-list-item " data-categoryid="44052">Neuroscience and Psychiatry</span></li> <li><span class="category-list-item " data-categoryid="44053">Notable Notes</span></li> <li><span class="category-list-item " data-categoryid="5787">Nursing</span></li> <li><span class="category-list-item " data-categoryid="5788">Nutrition</span></li> <li><span class="category-list-item " data-categoryid="44027">Nutrition, Obesity, Exercise</span></li> <li><span class="category-list-item " data-categoryid="5791">Obesity</span></li> <li><span class="category-list-item " data-categoryid="44013">Obstetrics and Gynecology</span></li> <li><span class="category-list-item " data-categoryid="5796">Occupational Health</span></li> <li><span class="category-list-item " data-categoryid="5801">Oncology</span></li> <li><span class="category-list-item " data-categoryid="5804">Ophthalmology</span></li> <li><span class="category-list-item " data-categoryid="5808">Orthopedics</span></li> <li><span class="category-list-item " data-categoryid="5811">Otolaryngology</span></li> <li><span class="category-list-item " data-categoryid="44028">Pain Medicine</span></li> <li><span class="category-list-item " data-categoryid="46446">Palliative Care</span></li> <li><span class="category-list-item " data-categoryid="44029">Pathology and Laboratory Medicine</span></li> <li><span class="category-list-item " data-categoryid="45306">Patient Care</span></li> <li><span class="category-list-item " data-categoryid="6258">Patient Information</span></li> <li><span class="category-list-item " data-categoryid="5843">Pediatrics</span></li> <li><span class="category-list-item " data-categoryid="44060">Performance Improvement</span></li> <li><span class="category-list-item " data-categoryid="45315">Performance Measures</span></li> <li><span class="category-list-item " data-categoryid="42050">Perioperative Care and Consultation</span></li> <li><span class="category-list-item " data-categoryid="42125">Pharmacoeconomics</span></li> <li><span class="category-list-item " data-categoryid="42126">Pharmacoepidemiology</span></li> <li><span class="category-list-item " data-categoryid="5851">Pharmacogenetics</span></li> <li><span class="category-list-item " data-categoryid="44030">Pharmacy and Clinical Pharmacology</span></li> <li><span class="category-list-item " data-categoryid="5856">Physical Medicine and Rehabilitation</span></li> <li><span class="category-list-item " data-categoryid="42059">Physical Therapy</span></li> <li><span class="category-list-item " data-categoryid="45313">Physician Leadership</span></li> <li><span class="category-list-item " data-categoryid="44061">Poetry</span></li> <li><span class="category-list-item " data-categoryid="45316">Population Health</span></li> <li><span class="category-list-item " data-categoryid="46445">Primary Care</span></li> <li><span class="category-list-item " data-categoryid="45309">Professional Well-being</span></li> <li><span class="category-list-item " data-categoryid="44064">Professionalism</span></li> <li><span class="category-list-item " data-categoryid="5871">Psychiatry and Behavioral Health</span></li> <li><span class="category-list-item " data-categoryid="42128">Public Health</span></li> <li><span class="category-list-item " data-categoryid="5877">Pulmonary Medicine</span></li> <li><span class="category-list-item " data-categoryid="42129">Radiology</span></li> <li><span class="category-list-item " data-categoryid="42058">Regulatory Agencies</span></li> <li><span class="category-list-item " data-categoryid="46443">Reproductive Health</span></li> <li><span class="category-list-item " data-categoryid="5916">Research, Methods, Statistics</span></li> <li><span class="category-list-item " data-categoryid="42142">Resuscitation</span></li> <li><span class="category-list-item " data-categoryid="5896">Rheumatology</span></li> <li><span class="category-list-item " data-categoryid="46326">Risk Management</span></li> <li><span class="category-list-item " data-categoryid="38802">Scientific Discovery and the Future of Medicine</span></li> <li><span class="category-list-item " data-categoryid="46495">Sexual Health</span></li> <li><span class="category-list-item " data-categoryid="5833">Shared Decision Making and Communication</span></li> <li><span class="category-list-item " data-categoryid="5912">Sleep Medicine</span></li> <li><span class="category-list-item " data-categoryid="5915">Sports Medicine</span></li> <li><span class="category-list-item " data-categoryid="5533">Stem Cell Transplantation</span></li> <li><span class="category-list-item " data-categoryid="5921">Substance Use and Addiction Medicine</span></li> <li><span class="category-list-item " data-categoryid="5923">Surgery</span></li> <li><span class="category-list-item " data-categoryid="44065">Surgical Innovation</span></li> <li><span class="category-list-item " data-categoryid="44066">Surgical Pearls</span></li> <li><span class="category-list-item " data-categoryid="44067">Teachable Moment</span></li> <li><span class="category-list-item " data-categoryid="44034">The Art of JAMA</span></li> <li><span class="category-list-item " data-categoryid="44037">The Arts and Medicine</span></li> <li><span class="category-list-item " data-categoryid="6257">The Rational Clinical Examination</span></li> <li><span class="category-list-item " data-categoryid="5936">Tobacco and e-Cigarettes</span></li> <li><span class="category-list-item " data-categoryid="5938">Toxicology</span></li> <li><span class="category-list-item " data-categoryid="46433">Translational Medicine</span></li> <li><span class="category-list-item " data-categoryid="42136">Trauma and Injury</span></li> <li><span class="category-list-item " data-categoryid="5942">Treatment Adherence</span></li> <li><span class="category-list-item " data-categoryid="46323">Ultrasonography</span></li> <li><span class="category-list-item " data-categoryid="5947">Urology</span></li> <li><span class="category-list-item " data-categoryid="44069">Users' Guide to the Medical Literature</span></li> <li><span class="category-list-item " data-categoryid="5950">Vaccination</span></li> <li><span class="category-list-item " data-categoryid="5955">Venous Thromboembolism</span></li> <li><span class="category-list-item " data-categoryid="45312">Veterans Health</span></li> <li><span class="category-list-item " data-categoryid="5957">Violence</span></li> <li><span class="category-list-item " data-categoryid="42139">Women's Health</span></li> <li><span class="category-list-item " data-categoryid="45307">Workflow and Process</span></li> <li><span class="category-list-item " data-categoryid="42140">Wound Care, Infection, Healing</span></li> </ul> </div> <div class="manage-interests--save-preferences"> <div class="save-preferences-btn thm-bg "> <span class="save-preferences-btn-text fw-b">Save Preferences</span> </div> </div> <div class="manage-interests--privacy-terms"> <a class="manage-interests--privacy-terms-color" href="/pages/privacy-policy">Privacy Policy</a> | <a class="manage-interests--privacy-terms-color" href="/pages/terms-of-use">Terms of Use</a></div> <a class="close-reveal-modal icon-close"></a> </div> </div> </div> <h4 class="thm-col-sec" align="center"> Others Also Liked </h4> <div id="trendmd-suggestions"></div> </div> <div id="comments-tab" class="resource-tab js-resource-tab comments-tab js-comments-tab single-comment-view"> </div> </div> </div> <a id="skip-to-navigation" href="#" tabindex="-1"></a> <div id="content-panel" class="content-panel"> <a id="top"></a> <div id="full-text-tab" class="resource-tab js-resource-tab full-text-tab"> <div class="widget-ArticleLinks widget-instance-AMA_ErrataArticleLinks_FullText"> </div> <div class="widget-ArticleLinks widget-instance-AMA_ArticleLinks_ToErrata_FullText"> </div> <div class="widget-ArticleNavLinks widget-instance-AMA_ArticleNavLinks"> <a class="toc-link btn" href="https://jamanetwork.com/journals/jamainternalmedicine/issue/176/2">This Issue</a> </div> <div class="article-metrics-wrapper" id="divArticleLevelMetrics"> <div class="widget-ArticleLevelMetrics widget-instance-AMA_ArticleMetrics"> <div class="artmet-condensed-wrap clearfix"> <div class="artmet-condensed-stats clearfix"> <div class="artmet-item artmet-views"> <span class="artmet-text sb-sc">Views</span> <span class="artmet-number sb-sc">8,748</span> </div> <div class="artmet-item artmet-citations"> <a class="artmet-citations-link" href="https://www.webofscience.com/api/gateway?GWVersion=2&SrcApp=silverchair&SrcAuth=WosAPI&KeyUT=WOS:000369627600010&DestLinkType=FullRecord&DestApp=WOS_CPL" target="_blank"> <span class="artmet-text">Citations</span> <span class="artmet-number">33</span> </a> </div> <div class="artmet-item artmet-altmetric"> <div class="widget-AltmetricLink widget-instance-AMAv2_ArticleLevelMetrics_AltmetricLinkSummary">  <div id="altmetricEmbedId" class='altmetric-embed' data-link-target="_blank" data-badge-type="text" data-hide-no-mentions="false" data-doi="10.1001/jamainternmed.2015.6840" ></div> </div> </div> </div> <div class="artmet-modal-trigger-wrap"> <a rel="nofollow" class="artmet-modal-trigger" data-article-id="2472948"><i class="icon-metrics"></i><span>View Metrics</span></a> </div> </div> </div> </div> <ul class="toolbar"> <li class="toolbar-pdf-wrap toolbar-tool-wrap"> <a id="pdf-link" href="/journals/jamainternalmedicine/articlepdf/2472948/ioi150093.pdf" class="toolbar-tool toolbar-pdf al-link pdfaccess js-pdfaccess" data-article-id="2472948" data-article-url="/journals/jamainternalmedicine/articlepdf/2472948/ioi150093.pdf" data-ajax-url="/Content/CheckPdfAccess"><span class="toolbar-pdf-text"><span class="toolbar-link-text-extra">Download </span><span class="toolbar-link-text">PDF</span></span> </a> </li> <li class="toolbar-share-wrap toolbar-tool-wrap"> <div class="toolbar-tool"> <a class="st-custom-button addthis_button_twitter is-b toolbar-twitter toolbar-share" data-network="twitter" data-title="" data-url="" data-email-subject="" rel="nofollow" href="javascript:;"> <span class="share-text">X</span> </a> <a class="st-custom-button addthis_button_facebook is-b toolbar-facebook toolbar-share" data-network="facebook" data-title="" data-url="" data-email-subject="" rel="nofollow" href="javascript:;"> <span class="share-text">Facebook</span> </a> <a class="toolbar-share-more-link is-a" rel="nofollow"><span class="icon icon-carrot_down social-arrow"></span><span class="more-text-wrap">More</span></a> <div class="toolbar-share-more"> <a class="st-custom-button addthis_button_linkedin is-b toolbar-linkedin toolbar-share" data-network="linkedin" data-title="" data-url="" data-email-subject="" rel="nofollow" href="javascript:;"> <span class="share-text">LinkedIn</span> </a> </div> </div> </li> <li class="toolbar-citation-wrap toolbar-tool-wrap"> <div class="widget-ToolboxGetCitation widget-instance-AMA_Get_Citation"> <a class="toolbar-tool toolbar-citation is-b stats-citation" rel="nofollow" data-reveal-id="get-citation" data-reveal> <span class="toolbar-link-text">Cite</span> <span class="toolbar-link-text-extra">This</span> </a> <div id="get-citation" class="reveal-modal get-citation" data-reveal> <h3 class="get-citation-title">Citation</h3> <p class="get-citation-citation">Fenton JJ<span class='al-author-delim'>, </span>Kravitz RL<span class='al-author-delim'>, </span>Jerant A, et al. Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests<span class="subtitle"><span class="colon-for-citation-subtitle">: </span>A Randomized Clinical Trial</span>. <em>JAMA Intern Med.</em> 2016;176(2):191–197. doi:10.1001/jamainternmed.2015.6840</p> <h4 class="get-citation-download-heading">Manage citations:</h4> <div class="get-citation-types"> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=0">Ris (Zotero)</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=1">EndNote</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=2">BibTex</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=3">Medlars</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=0">ProCite</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=3">RefWorks</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=0">Reference Manager</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2472948&resourceType=3&citationFormat=0">Mendeley</a> </div> <p class="get-citation-copyright">© 2024 </p> <a class="close-reveal-modal icon-close" rel="nofollow"></a> </div> </div> </li> <li class="toolbar-permissions-wrap toolbar-tool-wrap"> <div class="widget-ToolboxPermissions widget-instance-AMA_Get_Permissions"> <a href="http://s100.copyright.com/AppDispatchServlet?publisherName=AMA&publication=2168-6106&title=Promoting+Patient-Centered+Counseling+to+Reduce+Use+of+Low-Value+Diagnostic+Tests%3a+A+Randomized+Clinical+Trial&publicationDate=2016-02-01&volumeNum=176&issueNum=2&author=Fenton%2c+Joshua+J.%3b+Kravitz%2c+Richard+L.&startPage=191&endPage=197&contentId=10.1001%2fjamainternmed.2015.6840&oa=&orderBeanReset=True" rel="nofollow" id="PermissionsLink" class="toolbar-tool toolbar-permissions is-b" target="_blank"><span class="toolbar-link-text">Permissions</span></a> </div> </li> </ul> <div class="widget-ArticleTopInfo widget-instance-AMA_ArticleTop_Info_Widget"> <div class="meta-access-type free-access is-b"></div> <span class="hide tagmanagervalue" data-attribute="articleId" data-value="2472948" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="arrArticleAuthor" data-value="Joshua%20J.%C2%A0Fenton%2C%C2%A0MD%2C%20MPH,Richard%20L.%C2%A0Kravitz%2C%C2%A0MD%2C%20MSPH,Anthony%C2%A0Jerant%2C%C2%A0MD,Debora%20A.%C2%A0Paterniti%2C%C2%A0PhD,Heejung%C2%A0Bang%2C%C2%A0PhD,Donna%C2%A0Williams%2C%C2%A0MD,Ronald%20M.%C2%A0Epstein%2C%C2%A0MD,Peter%C2%A0Franks%2C%C2%A0MD" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="articleDOI" data-value="10.1001/jamainternmed.2015.6840" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articleTitle" data-value="Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests<span class="subtitle"><span class="colon-for-citation-subtitle">: </span>A Randomized Clinical Trial</span>" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="type" data-value="Original Investigation" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="thematicLabel" data-value="Less Is More" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="issueVolume" data-value="176" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="issueNo" data-value="2" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="publishDate" data-value="February 1, 2016" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="topics" data-value="Radiology, Medical Education and Training, Geriatrics, Osteoporosis, Shared Decision Making and Communication" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="topicCode" data-value="42129, 5739, 5668, 5810, 5833" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="category" data-value="Research" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="journalClub" data-value="No" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentStatus" data-value="Free" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articlePubState" data-value="Final" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentMedium" data-value="Article" data-type="string"></span> <div class="meta-article-type-wrap"> <div class="meta-article-type thm-col">Original Investigation </div> <div class="meta-super-class">Less Is More</div> </div> <div class="meta-date"><span class="ppub"><span class="month">February </span><span class="year">2016</span></span></div> <div class="meta-article-title-wrap"> <h1 class="meta-article-title ">Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests<span class="subtitle"><span class="colon-for-citation-subtitle">: </span>A Randomized Clinical Trial</span></h1> </div> <div class="meta-authors"> <span class="meta-authors--limited"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Joshua+J.+Fenton&q=Joshua+J.+Fenton" rel=nofollow target="_blank">Joshua J. Fenton, MD, MPH<sup>1,2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Richard+L.+Kravitz&q=Richard+L.+Kravitz" rel=nofollow target="_blank">Richard L. Kravitz, MD, MSPH<sup>2,3</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Anthony+Jerant&q=Anthony+Jerant" rel=nofollow target="_blank">Anthony Jerant, MD<sup>1,2</sup></a></span>; <a class="meta-authors--etal td-u stats-meta-authors--etal">et al</a></span> <span class="meta-authors--remaining"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Debora+A.+Paterniti&q=Debora+A.+Paterniti" rel=nofollow target="_blank">Debora A. Paterniti, PhD<sup>2,4</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Heejung+Bang&q=Heejung+Bang" rel=nofollow target="_blank">Heejung Bang, PhD<sup>5</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Donna+Williams&q=Donna+Williams" rel=nofollow target="_blank">Donna Williams, MD<sup>3</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Ronald+M.+Epstein&q=Ronald+M.+Epstein" rel=nofollow target="_blank">Ronald M. Epstein, MD<sup>6,7</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Peter+Franks&q=Peter+Franks" rel=nofollow target="_blank">Peter Franks, MD<sup>1,2</sup></a></span></span> </div> <div class="meta-author"> <a class="meta-author-title is-b stats-meta-author-toggle" data-tog-target=".meta-author-content">Author Affiliations</a> <a class="meta-articleinfo-jumplink section-jump-link scroll-to stats-scroll-to-articleinfo" data-tab-toggle=".tab-nav-full-text" href="#115616595">Article Information</a> <div class="meta-author-content"> <ul class="meta-author-affiliations"> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>1</sup>Department of Family and Community Medicine, University of California–Davis, Sacramento</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>2</sup>Center for Healthcare Policy and Research, University of California–Davis, Sacramento</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>3</sup>Department of Internal Medicine, University of California–Davis, Sacramento</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>4</sup>Department of Sociology, University of California–Davis, Sacramento</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>5</sup>Division of Public Health Sciences, University of California–Davis, Sacramento</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>6</sup>Department of Family Medicine, University of Rochester, Rochester, New York</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>7</sup>Center for Communications and Disparities Research, University of Rochester, Rochester, New York</div> </li> </ul> </div> </div> <div class="meta-citation-wrap"> <span class="meta-citation-journal-name">JAMA Intern Med. </span><span class="meta-citation"> 2016;176(2):191-197. doi:10.1001/jamainternmed.2015.6840</span> </div> </div> <div class="widget-EditorsChoice widget-instance-AMA_EditorsChoice_Links"> <div class="sm-linked-content"> <div class="sm-linked-content--item"> <a href="http://sites.jamanetwork.com/jama-medical-education/index.html" target="_blank" class="sm-linked-content--link fw-b sb-tc"><i class="icon-url d-ib thm-col"></i>2015 JAMA Network Medical Education Website</a> </div> </div> </div> <div class="widget-LinkedContentToolbar widget-instance-AMA_LinkedContentToolbar"> <div class="linked-content-toolbar"> <div class="hidden js-search-open-multimedia-by-default" showContentByDefault="False"></div> <div class="linked-content-controls"> <a class="linked-content-trigger td-n stats-graphical-abstract" href="#graphical-abstract-tab"> <i class="icon-visual-abstract"><span class="sr-t">visual abstract icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Visual <div>Abstract</div></div> </a> <a class="linked-content-trigger td-n stats-editorial-comment" href="#editorial-comment-tab"> <i class="icon-document"><span class="sr-t">editorial comment icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Editorial <div>Comment</div></div> </a> <a class="linked-content-trigger td-n stats-related-articles" href="#related-articles-tab"> <i class="icon-related"><span class="sr-t">related articles icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Related <div>Articles</div></div> </a> <a class="linked-content-trigger td-n stats-author-interviews" href="#author-interviews-tab"> <i class="icon-author_interview"><span class="sr-t">author interview icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Interviews</div> </a> <a class="linked-content-trigger td-n stats-more-multimedia" href="#more-multimedia-tab"> <i class="icon-multimedia"><span class="sr-t">multimedia icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Multimedia</div> </a> <a class="linked-content-trigger td-n stats-listen-to-this-article" href="#listen-to-this-article-tab"> <i class="icon-audio"><span class="sr-t">audio icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Listen to <div>this article</div></div> </a> </div> <div class="linked-content-tabs"> <div id="graphical-abstract-tab" class="linked-content-tab graphical-abstract-tab"> <div class="widget-SectionDisplay widget-instance-AMA_GraphicalAbstract_Tab"> </div> </div> <div id="editorial-comment-tab" class="linked-content-tab editorial-comment-tab"> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_EditorialComments"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472942"> <div class="related-article-type">Editorial</div> <div class="related-article-title sb-tc">Research in Medical Education and Patient-Centered Outcomes</div> </a> <div class="related-article-authors">Patrick G. O’Malley, MD, MPH; Louis N. Pangaro, MD</div> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472944"> <div class="related-article-type">Invited Commentary</div> <div class="related-article-title sb-tc">Health Policy and Medical Training</div> </a> <div class="related-article-authors">Rachel J. Stern, MD</div> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472943"> <div class="related-article-type">Editor's Note</div> <div class="related-article-title sb-tc">An Intervention to Reduce Use of Low-Value Imaging Tests</div> </a> <div class="related-article-authors">Kenneth E. Covinsky, MD; Rita F. Redberg, MD</div> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> </ul> </div> </div> <div id="related-articles-tab" class="linked-content-tab related-article-tab"> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_RelatedArticle"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472945"> <div class="related-article-type">Research Letter</div> <div class="related-article-title sb-tc">Patterns of Needlestick and Sharps Injuries Among Training Residents</div> </a> <div class="related-article-authors">Thomas Marnejon, DO; David Gemmel, PhD; Kelli Mulhern, BS</div> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472946"> <div class="related-article-type">Research Letter</div> <div class="related-article-title sb-tc">Electronic Audit of an Inpatient Service</div> </a> <div class="related-article-authors">David Ouyang, MD; Jonathan H. Chen, MD, PhD; Jason Hom, MD; Jeffrey Chi, MD</div> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2472947"> <div class="related-article-type">Research Letter</div> <div class="related-article-title sb-tc">Southern Medical Students’ Views on Medicaid Expansion</div> </a> <div class="related-article-authors">Esme B. Cullen; Karen E. Hauer, MD, PhD; Leo Eisenstein; Christy K. Boscardin, PhD; Steven A. Schroeder, MD</div> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> </ul> </div> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_RelatedEditorsChoices"> </div> </div> <div id="author-interviews-tab" class="linked-content-tab linked-author-interviews-tab"> <div class="widget-AudioPlayer widget-instance-AMA_LinkedContentToolbar_PlatformAudioPlayer_AuthorInterviews"> </div> </div> <div id="listen-to-this-article-tab" class="linked-content-tab linked-listen-to-this-article-tab"> <div class="widget-AudioPlayer widget-instance-AMA_LinkedContentToolbar_PlatformAudioPlayer_ListenToThisArticle"> </div> </div> <div id="more-multimedia-tab" class="linked-content-tab more-multimedia-tab"> </div> </div> </div> </div> <div class="widget-ArticleFulltext widget-instance-AMA_Article_FullText_Widget"> <div class="article-full-text" data-userHasAccess="True"> <a class="article-section-id-anchor" id="115616537"></a> <div class="h3 cb section-type-abstract decorated-hed "> <div class="heading-text thm-col sb-sc"> Abstract </div> </div> <p><strong>Importance</strong> <span>Low-value diagnostic tests have been included on primary care specialty societies’ “Choosing Wisely” Top Five lists.</span></p><p><strong>Objective</strong> <span>To evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests.</span></p><p><strong>Design, Setting, and Participants</strong> <span>Randomized clinical trial of 61 general internal medicine or family medicine residents at 2 residency-affiliated primary care clinics at an academic medical center in California.</span></p><p><strong>Interventions</strong> <span>Two simulated visits with SP instructors portraying patients requesting inappropriate spinal magnetic resonance imaging for low back pain or screening dual-energy x-ray absorptiometry. The SP instructors provided personalized feedback to residents regarding use of 6 patient-centered techniques to address patient concerns without ordering low-value tests. Control group physicians received SP visits without feedback and were emailed relevant clinical guidelines.</span></p><p><strong>Main Outcomes and Measures</strong> <span>The primary outcome was whether resident PCPs ordered SP-requested low-value tests during up to 3 unannounced SP clinic visits over 3 to 12 months follow-up, with patients requesting spinal magnetic resonance imaging, screening dual-energy x-ray absorptiometry, or headache neuroimaging. Secondary outcomes included PCP patient-centeredness and use of targeted techniques (both coded from visit audiorecordings), and SP satisfaction with the visit (0-10 scale).</span></p><p><strong>Results</strong> <span>Of 61 randomized resident PCPs (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up. Compared with control PCPs, intervention PCPs had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 [95% CI, 42.0 to 45.7] vs 43.7 [95% CI, 41.8 to 45.6], adjusted mean difference, −0.2 [95% CI, −2.9 to 2.5]; <i>P</i> = .90) and used a similar number of targeted techniques (5.4 [95% CI, 4.9 to 5.8] vs 5.4 [95% CI, 4.9 to 5.8] on a 0-9 scale, adjusted mean difference, 0 [95% CI, −0.7 to 0.6]; <i>P</i> = .96). Residents ordered low-value tests in 41 SP encounters (26.5% [95% CI, 19.7%-34.1%]) with no significant difference in the odds of test ordering in intervention PCPs relative to control group PCPs (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Rates of test ordering among intervention and control PCPs were similar for all 3 SP cases. The SPs rated visit satisfaction higher among intervention than control PCPs (8.5 [95% CI, 8.1-8.8] vs 7.8 [95% CI, 7.5-8.2], adjusted mean difference, 0.6 [95% CI, 0.1-1.1]).</span></p><p><strong>Conclusions and Relevance</strong> <span>An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents.</span></p><p><strong>Trial Registration</strong> <span>clinicaltrials.gov Identifier: <a href="http://clinicaltrials.gov/show/NCT01808664">NCT01808664</a></span></p> <div class="movable-ad-target bta"> </div> <a class="article-section-id-anchor" id="115616542"></a> <div class="h3 cb section-type-section "> <div class="heading-text thm-col sb-sc"> Introduction </div> </div> <a class="article-section-id-anchor" id="115616543"></a> <p class="para">As part of the “Choosing Wisely” initiative, more than 70 physician specialty societies have issued “Top Five” lists of clinical practice changes that physicians could enact to augment US health care value. Initial criteria for inclusion on a Top Five list were that (1) the service is frequently misused, (2) it has a substantial financial impact, and (3) reducing use of the service is within the power of physicians and would either improve or have no deleterious effect on population health.<sup><a href="#ioi150093r1" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">1</a></sup></p> <a class="article-section-id-anchor" id="115616544"></a> <p class="para">Because of limited or absent benefits and potential harms,<sup><a href="#ioi150093r2" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">2</a></sup><sup>,<a href="#ioi150093r3" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">3</a></sup> 2 diagnostic imaging tests appear on the lists of the American College of Physicians and the American Academy of Family Physicians: the use of advanced spinal imaging (eg, magnetic resonance imaging [MRI] or computed tomography [CT] scan) in patients with recent-onset uncomplicated back pain, and dual-energy x-ray absorptiometry (DXA) screening in women younger than 65 years without osteoporosis risk factors.<sup><a href="#ioi150093r4" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">4</a></sup> Meanwhile, in its Top Five list, the American College of Radiology advises against neuroimaging in patients with uncomplicated headache because of low likelihood of benefit and potential harms stemming from incidental findings.<sup><a href="#ioi150093r4" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">4</a></sup></p> <a class="article-section-id-anchor" id="115616545"></a> <p class="para">Patient requests, prompted by worries about serious underlying disease, may be one factor driving overuse of these diagnostic tests. However, patient-centered communication may allow physicians to address patient concerns without ordering requested low-value services.<sup><a href="#ioi150093r5" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">5</a></sup><sup>,<a href="#ioi150093r6" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">6</a></sup> Indeed, observational studies have found that physicians with more patient-centered communication styles order diagnostic tests significantly less frequently than those with less patient-centered communication styles.<sup><a href="#ioi150093r7" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">7</a></sup></p> <a class="article-section-id-anchor" id="115616546"></a> <p class="para">Although physician-level interventions have successfully improved the patient-centeredness of patient-physician interactions, most have required hours or days of training away from the clinical setting.<sup><a href="#ioi150093r8" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">8</a></sup> Standardized patient instructors (SPIs) are a potentially efficient means of delivering physician education in the context of routine clinical care. Previous SPI-based interventions have shown promise in changing primary care physician (PCP) communication behaviors.<sup><a href="#ioi150093r9" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">9</a></sup><sup>,<a href="#ioi150093r10" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">10</a></sup></p> <a class="article-section-id-anchor" id="115616547"></a> <p class="para">In a randomized clinical trial, we assessed the use of SPIs to enhance the patient-centered communication skills of resident PCPs in the context of patient requests for low-value diagnostic tests. We hypothesized that the intervention would increase patient-centeredness and, in turn, reduce ordering of requested tests in subsequent simulated office visits with unannounced standardized patients (SPs).</p> <a class="article-section-id-anchor" id="115616548"></a> <div class="h3 cb section-type-section "> <div class="heading-text thm-col sb-sc"> Methods </div> </div> <a class="article-section-id-anchor" id="115616549"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Design and Setting </div> </div> <a class="article-section-id-anchor" id="115616550"></a> <p class="para">We conducted a randomized clinical trial of an intervention delivered during 2 simulated office visits with SPIs who provided personalized feedback to resident physicians in internal medicine or family medicine at the University of California–Davis Medical Center in Sacramento, California. Intervention visits occurred from September 1, 2013, to December 31, 2013, with longitudinal follow-up conducted through September 30, 2014. The institutional review board at the University of California–Davis approved the study prior to data collection, and all participants provided oral consent.</p> <a class="article-section-id-anchor" id="115616551"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Participants </div> </div> <a class="article-section-id-anchor" id="115616552"></a> <p class="para">General internal medicine and family medicine resident physicians were eligible for inclusion if they were in postgraduate year 2 or greater on July 1, 2013, and would be providing regular primary care at either clinic through June 30, 2014. Residents were invited to participate in a study of “patient-doctor communication” during group didactic sessions, grand rounds, and administrative meetings. Interested residents provided verbal informed consent in accord with protocols approved by the University of California–Davis institutional review board. Enrolled residents were randomly assigned in 1:1 ratio to intervention and control groups in blocks of 8. Investigators and the study coordinator were blinded to intervention assignment.</p> <a class="article-section-id-anchor" id="115616553"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Intervention and Control Conditions </div> </div> <a class="article-section-id-anchor" id="115616554"></a> <p class="para">We developed an SPI-delivered intervention emphasizing a collaborative interaction<sup><a href="#ioi150093r11" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">11</a></sup><sup>,<a href="#ioi150093r12" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">12</a></sup> that included 6 steps that were congruent with core elements of patient-centered care<sup><a href="#ioi150093r13" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">13</a></sup>: (1) understand the patient’s concerns and expectations before addressing them; (2) validate the patient’s concerns and emotions using empathy and normalization; (3) inform the patient about reassuring features of the history and examination; (4) explain that you do not recommend the test because risks outweigh benefits; (5) flexibly negotiate alternatives to testing; and (6) explore for residual concerns. Preliminary versions of the intervention were refined during key informant interviews with senior PCPs and 2 focus groups with graduating residents.</p> <a class="article-section-id-anchor" id="115616555"></a> <p class="para">The final intervention was delivered during 2 simulated office visits with SPIs, one portraying a 48-year-old man with subacute back pain requesting a spinal MRI, the other a 52-year-old woman requesting a screening DXA. In both visits, the SPIs spent approximately 20 minutes in role. Subsequently, SPIs broke out of roles, used handheld visual props to present the 6-step approach, and provided personalized feedback on the extent to which physicians fulfilled each step. The SPIs used scripts to tailor positive or constructive feedback and encouraged residents to practice techniques by role-playing. The intervention phase of each visit lasted approximately 10 minutes.</p> <a class="article-section-id-anchor" id="115616556"></a> <p class="para">Control PCPs received simulated visits with 2 SPIs portraying cases identical to those used in intervention visits. After approximately 20 minutes in role during control visits, SPIs ended the visits without discussing intervention steps or providing feedback. After control visits, staff sent control physicians clinical guidelines on back pain and osteoporosis evaluation and treatment via email.<sup><a href="#ioi150093r14" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">14</a></sup><sup>,<a href="#ioi150093r15" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">15</a></sup> Across all enrolled residents, the 2 SPI visits occurred a median of 33 days apart (interquartile range, 27-50 days).</p> <a class="article-section-id-anchor" id="115616557"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> SP Measurement Visits </div> </div> <a class="article-section-id-anchor" id="115616558"></a> <p class="para">We assessed the impact of the intervention on resident practice behavior during subsequent visits with unannounced SPs scheduled during regular primary care office hours. We planned for each PCP to receive up to 3 SP visits over a 3- to 12-month follow-up period, including visits with (1) a male patient with subacute back pain without “red flag” symptoms or signs requesting spinal MRI, (2) a postmenopausal woman at low risk for osteoporosis with fatigue requesting a screening DXA, and (3) a 30-year-old woman with recent-onset headache without high-risk features requesting neuroimaging. We designed the case histories of the first 2 patients to overlap with training SPI cases, whereas the third was designed to test for generalization of intervention effects to low-value tests that were not directly targeted.</p> <a class="article-section-id-anchor" id="115616559"></a> <p class="para">Using detailed case histories, 9 SPs were trained to portray patients convincingly, to request tests early during visits, and to accept omission of testing if residents used patient-centered techniques emphasized in the intervention. For each visit, SPs had unique names and electronic medical records, and staff checked in SPs routinely like other patients arriving for clinic visits. As a result of technical hurdles, we could not populate the electronic medical records with prior case notes, so SPs represented new rather than established patients. The SPs were blinded to resident allocation to intervention vs control. The SPs audiorecorded visits using a recorder concealed in a bag or purse. </p> <a class="article-section-id-anchor" id="115616560"></a> <p class="para">In each clinic, resident physicians are expected to precept all patients with attending faculty physicians. Faculty physicians were notified repeatedly during staff meetings and by email regarding the purpose and design of the study and the general case histories of the follow-up SPs. We requested that faculty provide nondirective advice to residents if they suspected that the resident was seeing an SP. Residents can electronically order the targeted diagnostic tests without attending physician co-signature.</p> <a class="article-section-id-anchor" id="115616561"></a> <p class="para">We monitored SP detection by asking the residents via emailed survey 2 to 4 weeks after SP visits whether they suspected seeing an SP recently. If residents suspected seeing SPs, the survey asked them to describe the SP and whether their clinical decisions differed from what they might have done with a real patient.</p> <a class="article-section-id-anchor" id="115616562"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Fidelity Monitoring </div> </div> <a class="article-section-id-anchor" id="115616563"></a> <p class="para">Using standard checklists, an SP supervisor prospectively monitored fidelity by listening to audiorecordings of selected SPI and SP visits, assessing role fidelity using a checklist, and for SPIs, correct presentation of intervention steps and appropriateness of resident feedback. On the basis of these assessments, the supervisor provided corrective feedback to SPIs and SPs.</p> <a class="article-section-id-anchor" id="115616564"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Main Outcome Measures </div> </div> <a class="article-section-id-anchor" id="115616565"></a> <p class="para">The primary outcome was whether residents ordered requested diagnostic tests during follow-up SP visits, which was assessed by means of standardized medical record review. Prespecified secondary outcomes included the patient-centeredness of resident-SP interactions, the extent to which residents used targeted techniques for handling requests for low-value tests, and SP global satisfaction with residents.</p> <a class="article-section-id-anchor" id="115616566"></a> <p class="para">Patient-centeredness was measured using the Measure of Patient-Centered Communication, a validated measure ranging from 0 to 100 (least to most patient-centered) based on coding audiorecordings.<sup><a href="#ioi150093r13" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">13</a></sup> Blinded to allocation to intervention vs control, 2 trained research assistants coded all audiorecordings, resolving disagreements by consensus. Coders also rated the extent to which physicians engaged in the following targeted communication behaviors: (1) normalization, (2) informing patients about reassuring features of history and physical examination, (3) explaining that the risks of testing outweighed the benefits, (4) advising watchful waiting, and (5) recommending evidence-based strategies instead of immediate testing. Acceptable evidence-based strategies were specified for each case (eg, increasing dietary calcium intake for women requesting DXA). The use of normalization was assessed as present or absent, whereas the other 4 items were rated on an ordinal scale (none, minimal, exemplary use). For analyses, we summed the 5 individual measures to create a single ordinal measure of the extent to which residents used targeted techniques (range, 0 to 9 from least to most). Coders also assessed the extent of SP interaction with the attending physician (none, minimal, or meaningful). Immediately after visits, SPs rated their global satisfaction with PCPs on a 0 to 10 scale (ranging from “worst” to “best provider possible”).</p> <a class="article-section-id-anchor" id="115616567"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Exploratory Outcomes </div> </div> <a class="article-section-id-anchor" id="115616568"></a> <p class="para">In exploratory analyses, we assessed potential intervention effects on diagnostic testing among actual adult patients (age ≥18 years) by identifying counts of diagnostic tests ordered during primary care visits with participating PCPs during the 1-year period prior to their first SPI visits and from the date of their final SPI visits through January 15, 2015. For these analyses, we included visit-level counts of these diagnostic test categories: hematology and chemistry, microbiology, imaging tests (subcategorized as nonspine plain x-ray or sonography, spinal x-ray, nonspine MRI or CT, spinal MRI or CT, neuroimaging), DXA, electrocardiography, other cardiac tests, and miscellaneous tests (eg, nuclear medicine). We excluded tests performed for screening or prevention (eg, lipid or diabetes mellitus tests, mammograms). We also collected patient-level covariates to enable stratified analyses by female sex and age (for DXA testing) and the presence of either back pain or headache <i>International Classification of Diseases, Ninth Revision, Clinical Modification</i> diagnoses (for spinal MRI/CT and neuroimaging, respectively).</p> <a class="article-section-id-anchor" id="115616569"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> PCP Variables </div> </div> <a class="article-section-id-anchor" id="115616570"></a> <p class="para">Resident sex, postgraduate year, and specialty (family or internal medicine) were provided by residency staff. Residents completed baseline questionnaires providing age and measures of stress from uncertainty and reluctance to disclose uncertainty (theoretical ranges, 13-78 and 9-39, with higher scores reflecting greater stress and reluctance, respectively).<sup><a href="#ioi150093r16" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">16</a></sup> Of 30 intervention residents, 29 completed a brief questionnaire eliciting opinions and the quality and relevance of the SPI training (response rate, 97%).</p> <a class="article-section-id-anchor" id="115616571"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Sample Size </div> </div> <a class="article-section-id-anchor" id="115616572"></a> <p class="para">Assuming an intraclass correlation of 0.1 for the dichotomous primary outcome,<sup><a href="#ioi150093r17" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">17</a></sup> we estimated that a sample of 190 SP visits (95 in both intervention and control arms nested within physicians) would yield 80% power to detect a difference of 45% test ordering in control vs 25% in intervention groups.</p> <a class="article-section-id-anchor" id="115616573"></a> <div class="h4 cb section-type-section "> <div class="heading-text "> Statistical Analysis </div> </div> <a class="article-section-id-anchor" id="115616574"></a> <p class="para">Analyses were conducted using Stata, version 14.0. Analysts were blinded to resident allocation. To assess for intervention effects during SP visits, we used generalized linear mixed models (GLMMs) that included main effects for study arm (intervention vs control), SP visit number (first, second, or third), SP case (back pain, DXA, or headache), and resident-level random effects. For the binary outcome of whether requested tests were ordered, we used a log-link and binomial distribution, whereas for continuous and ordinal secondary outcomes, we used identity links and Gaussian distributions. Intervention effects were considered significant if the study arm term was statistically significant using a 2-tailed Wald hypothesis test (<i>P</i> < .05). Because of the randomized design, we did not adjust for physician characteristics in primary analyses. We repeated regression analyses using generalized estimating equations, which yielded similar results. We used the fitted GLMM model to predict testing probabilities by study arm and SP case while adjusting for SP visit number.</p> <a class="article-section-id-anchor" id="115616575"></a> <p class="para">For exploratory outcomes among actual patients, we used similar GLMM models with Poisson links to model counts of diagnostic tests per visit with study residents. Along with resident-level random effects, models included study arm, a binary variable signifying whether the visit occurred before or after the 2 SPI visits, and an interaction term between study arm and period (before vs after SPI visits). Intervention effect was assessed by examining the significance of the interaction term.</p> <a class="article-section-id-anchor" id="115616576"></a> <div class="h3 cb section-type-section "> <div class="heading-text thm-col sb-sc"> Results </div> </div> <a class="article-section-id-anchor" id="115616577"></a> <p class="para">Of 64 potentially eligible residents, 61 agreed to participate and were randomized, 59 of whom had at least 1 follow-up SP visit (<a href="#ioi150093f1" class="figure-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Figure 1</a>). Residents in the intervention and control groups were similar with regard to baseline characteristics, although a higher proportion of intervention residents were women compared with controls (73% vs 52%) (<a href="#ioi150093t1" class="table-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Table 1</a>). In postintervention questionnaires, almost all intervention residents agreed or strongly agreed that the SPI training was “high quality” (26 of 29 [90%]), “helpful” (27 of 29 [93%]), and “relevant to practice” (29 of 29 [100%]).</p> <a class="article-section-id-anchor" id="115616580"></a> <p class="para">Residents had a mean of 2.6 SP follow-up visits (total, 155 visits), the first of which occurred a median (range) of 140 (51-330) days from the last SPI visit. For the 57 residents who had multiple SP visits, final SP visits occurred a median (range) of 253 (137-384) days after the last SPI visit. We received postvisit resident survey responses after 101 visits (response rate, 65.2%). Over the 101 postvisit surveys, residents suspected seeing recent SPs in 60 visits (59.4%), most commonly because in the internal medicine clinic that participated in the study, residents rarely see new patients. Standardized patients were suspected in a similar percentage of visits with intervention and control PCPs (32 of 51 [63%] vs 28 of 50 [56%], respectively; <i>P</i> = .49). In 53 of the 60 visits in which residents suspected seeing SPs (88%), PCPs responded that they managed the patient exactly as they would a similar real patient. Attending physicians interacted meaningfully with a similar proportion of SPs seen by intervention and control physicians (27 of 76 [36%] vs 25 of 78 [32%], respectively), with the remaining SPs having either minimal or no attending interaction.</p> <a class="article-section-id-anchor" id="115616581"></a> <p class="para">In the 155 encounters with SPs who requested low-value tests, residents ordered tests in 41 visits (26.5% [95% CI, 19.7%-34.1%]). After adjustment for visit number and case, receipt of the intervention was not associated with a significant difference in the odds of requested test ordering (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Requested tests were ordered for 21 of 47 (45% [95% CI, 30%-55%]) low-risk women requesting screening DXA, 15 of 55 (27% [95% CI, 15%-39%]) men with back pain requesting spinal MRI, and 5 of 53 (9% [95% CI, 1%-18%]) women with uncomplicated headache requesting neuroimaging. Within each SP case, intervention and control physicians had similar adjusted probabilities of ordering requested tests (<a href="#ioi150093f2" class="figure-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Figure 2</a>).</p> <a class="article-section-id-anchor" id="115616583"></a> <p class="para">Intervention receipt was not associated with significant differences in resident patient-centeredness or the use of targeted counseling techniques (<a href="#ioi150093t2" class="table-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Table 2</a>). The intervention, however, was associated with significantly higher SP ratings on a 10-point global satisfaction scale (adjusted mean difference, 0.6 [95% CI, 0.1-1.1]). The difference in global satisfaction persisted in 3 sensitivity analyses: (1) that adjusted for mean SPI ratings of global satisfaction collected after the 2 baseline training visits; (2) that adjusted for SP identity; and (3) that formulated satisfaction on the basis of mean SP response to items on physician communication included in the Clinician and Group Consumer Assessment of Health Plans Survey (data not shown). Analytic results of primary and secondary outcomes were unchanged when adjusted for physician sex. In analyses of diagnostic testing among actual patients seen by study residents, receipt of the intervention was not associated with significantly different testing rates during the postintervention period (<a href="#ioi150093t3" class="table-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Table 3</a>).</p> <a class="article-section-id-anchor" id="115616586"></a> <div class="h3 cb section-type-section "> <div class="heading-text thm-col sb-sc"> Discussion </div> </div> <a class="article-section-id-anchor" id="115616587"></a> <p class="para">In this randomized clinical trial, we evaluated the effectiveness of an SP-based educational intervention designed to increase resident skill and confidence in handling patient requests for low-value diagnostic tests. The intervention sought to augment the patient-centeredness of the residents’ responses to the patients’ requests while fostering the use of specific techniques designed to address patients’ concerns without acceding to their expressed wishes. Although the residents were enthusiastic about the quality and relevance of the intervention, the intervention did not affect either patient-centeredness of interactions or the use of targeted counseling techniques, nor did it reduce diagnostic test ordering either for SPs or for actual patients.</p> <a class="article-section-id-anchor" id="115616588"></a> <p class="para">Interventions ranging from audit and feedback to computerized order entry with integrated decision support have successfully modified physician use of diagnostic tests.<sup><a href="#ioi150093r18" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">18</a></sup><sup>-<a href="#ioi150093r18" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">20</a></sup> However, to our knowledge, no prior trials have tested interventions in the context of explicit patient requests for low-value testing.</p> <a class="article-section-id-anchor" id="115616589"></a> <p class="para">In 2 trials (conducted by members of our group), SPI-based interventions showed promise in modifying physician communication regarding HIV risk<sup><a href="#ioi150093r9" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">9</a></sup> and chronic disease self-management.<sup><a href="#ioi150093r10" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">10</a></sup> In the present study, however, several factors may have rendered the SPI intervention ineffective. First, the intervention may have been too limited in its intensity (~20 total minutes of intervention time over 2 SPI visits), in contrast to a successful SPI intervention to modify HIV counseling that was coupled with a 90-minute educational seminar.<sup><a href="#ioi150093r9" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">9</a></sup> One intervention resident, for example, commented, “Honestly, I would need a few more repetitions to get the principles in my mind … (so) that I would consistently execute them.” Second, the intervention focused on improving residents’ skills in eliciting and addressing patients’ concerns about requested low-value tests but did not target other factors that may drive low-value testing, such as prevailing norms in training environments encouraging comprehensive rather than judicious diagnostic testing, malpractice fears, or beliefs that the tests may actually have diagnostic value in the portrayed clinical scenarios.<sup><a href="#ioi150093r21" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">21</a></sup><sup>-<a href="#ioi150093r21" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">23</a></sup> Third, we compared the intervention to a control in which residents received emailed clinical guidelines that may have prompted control physicians to reduce testing. Finally, the first SP follow-up visit occurred a median of 140 days after the final SPI visit, so early intervention effects may have worn off prior to initial follow-up measures. In contrast, positive effects of an SPI intervention on chronic disease self-management counseling were measured within 1 month of the intervention.<sup><a href="#ioi150093r10" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">10</a></sup></p> <a class="article-section-id-anchor" id="115616590"></a> <p class="para">High rates of SP detection may have altered overall results, as residents may alter behavior when they suspect that they are seeing an SP. However, rates of detection were similar in intervention and control arms, and residents who suspected SPs believed that their management was not altered by their suspicion. In addition, we detected no evidence that the intervention affected the use of targeted techniques, which we would expect to precede actual test ordering. Finally, we found no evidence of an intervention effect on test ordering in actual patients. While overall test ordering in SP encounters may have been higher if detection rates were lower, we found no statistically significant favorable intervention effects on either simulated or actual test ordering or on counseling behaviors that we theorized would precede test ordering.</p> <a class="article-section-id-anchor" id="115616591"></a> <p class="para">Although intervention receipt did not improve patient-centeredness of SP encounters, the intervention was associated with higher ratings of global satisfaction by blinded SPs. We measured SP satisfaction mainly to ensure that an intervention designed to encourage omission of testing did not negatively affect the patient-physician relationship. In the absence of favorable changes in patient-centeredness, targeted behaviors, or test ordering, it is difficult to judge the clinical significance of higher ratings of SP satisfaction with intervention physicians. It is nevertheless conceivable that the intervention improved resident communication skills that were unmeasured by blinded coding for patient-centered behaviors.<sup><a href="#ioi150093r24" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">24</a></sup></p> <a class="article-section-id-anchor" id="115616592"></a> <p class="para">Our study was limited by the inclusion of only 2 academic practices in a single institution. We only studied resident physicians because we viewed residency training as a potentially formative period when counseling habits may be more easily modified. Results could differ among physicians in community practice. Because intervention and control residents practiced in the same settings, they may have discussed the intervention, introducing contamination. In addition, we lacked precision in estimating the relative odds of requested test ordering in intervention vs control encounters, because of a smaller than planned number of SP visits and lower than anticipated rates of test ordering. We also acknowledge the possible influence of attending teaching physicians on resident ordering or counseling behaviors.</p> <a class="article-section-id-anchor" id="115616593"></a> <div class="h3 cb section-type-section "> <div class="heading-text thm-col sb-sc"> Conclusions </div> </div> <a class="article-section-id-anchor" id="115616594"></a> <p class="para">An SPI-based intervention aiming to improve resident skill in handling patient requests for low-value tests had no effect on ordering of low-value tests during subsequent unannounced SP visits, nor did the intervention influence resident patient-centeredness, the use of targeted counseling techniques, or diagnostic testing among actual patients. Although the intervention was theoretically grounded and rated favorably by residents, an SPI intervention with such limited scope and duration cannot be recommended as a means of improving the value of diagnostic testing in primary care.</p> <a class="article-section-id-anchor" id="115616595"></a> <div class="h3 cb section-type-acknowledgements has-back-to-top"> <a href="#top" class="section-jump-link back-to-top" data-tab-toggle=".tab-nav-full-text">Back to top</a> <div class="heading-text thm-col sb-sc"> Article Information </div> </div> <p class="para"><strong>Accepted for Publication:</strong> October 8, 2015.</p><p class="authorInfoSection"><strong>Corresponding Author:</strong> Joshua J. Fenton, MD, MPH, Department of Family and Community Medicine, University of California–Davis Health System, 4860 Y St, Ste 2300, Sacramento, CA 95817 (<a href="mailto:jjfenton@ucdavis.edu" target="_blank">jjfenton@ucdavis.edu</a>).</p><p class="parapublished-online"><strong>Published Online:</strong> December 7, 2015. doi:10.1001/jamainternmed.2015.6840.</p><p class="paraauthor-contributions"><strong>Author Contributions:</strong> Dr Fenton had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.</p><p class="para"><i>Study concept and design: </i>All authors.</p><p class="para"><i>Acquisition, analysis, or interpretation of data: </i>Fenton, Jerant, Paterniti, Bang, Williams, Epstein, Franks.</p><p class="para"><i>Drafting of the manuscript: </i>Fenton, Bang.</p><p class="para"><i>Critical revision of the manuscript for important intellectual content: </i>All authors.</p><p class="para"><i>Statistical analysis: </i>Bang, Franks.</p><p class="para"><i>Obtained funding:</i>Fenton, Bang, Franks.</p><p class="para"><i>Administrative, technical, or material support: </i>Jerant, Williams, Epstein.</p><p class="para"><i>Study supervision: </i>Fenton, Paterniti, Williams, Epstein.</p><p class="parafinancial-disclosure"><strong>Conflict of Interest Disclosures:</strong> None reported.</p><p class="parafunding-statement"><strong>Funding/Support:</strong> This work was supported by the Patient-Centered Outcomes Research Institute.</p><p class="para"><strong>Role of the Funder/Sponsor:</strong> The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.</p> <a class="article-section-id-anchor" id="115616596"></a> <div class="h3 cb section-type-references "> <div class="heading-text thm-col sb-sc"> References </div> </div> <div class="references"><div class="reference"><a class="reference-number" id="ioi150093r1">1.</a><div class="reference-content">Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. <i xmlns:helper="urn:XsltStringHelper"> Arch Intern Med</i>. 2011;171(15):1385-1390.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/21606090" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=The%20%E2%80%9Ctop%205%E2%80%9D%20lists%20in%20primary%20care%3A%20meeting%20the%20responsibility%20of%20professionalism.&publication_year=2011&journal=Arch%20Intern%20Med&volume=171&pages=1385-1390" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/archinternmed.2011.231" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/archinternmed.2011.231" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r2">2.</a><div class="reference-content">Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. <i xmlns:helper="urn:XsltStringHelper"> JAMA</i>. 2003;289(21):2810-2818.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/12783911" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Rapid%20magnetic%20resonance%20imaging%20vs%20radiographs%20for%20patients%20with%20low%20back%20pain%3A%20a%20randomized%20controlled%20trial.&author=JG%20Jarvik&author=W%20Hollingworth&author=B%20Martin&publication_year=2003&journal=JAMA&volume=289&pages=2810-2818" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/jama.289.21.2810" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/jama.289.21.2810" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r3">3.</a><div class="reference-content">Järvinen TL, Michaëlsson K, Jokihaara J, et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. <i xmlns:helper="urn:XsltStringHelper"> BMJ</i>. 2015;350:h2088.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/26013536" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Overdiagnosis%20of%20bone%20fragility%20in%20the%20quest%20to%20prevent%20hip%20fracture.&author=TL%20Järvinen&author=K%20Michaëlsson&author=J%20Jokihaara&publication_year=2015&journal=BMJ&volume=350&pages=h2088" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1136/bmj.h2088" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1136/bmj.h2088" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r4">4.</a><div class="reference-content">Choosing Wisely: An Initiative of the ABIM Foundation. 2015. <a href="http://www.choosingwisely.org/">http://www.choosingwisely.org/</a>. Accessed July 9, 2015.</div></div><div class="reference"><a class="reference-number" id="ioi150093r5">5.</a><div class="reference-content">Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. <i xmlns:helper="urn:XsltStringHelper"> Patient-Centered Medicine: Transforming the Clinical Method.</i> Abingdon, England: Radcliffe Medical Press Ltd; 2003.</div></div><div class="reference"><a class="reference-number" id="ioi150093r6">6.</a><div class="reference-content">Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “no”: strategies primary care physicians use to deny patient requests. <i xmlns:helper="urn:XsltStringHelper"> Arch Intern Med</i>. 2010;170(4):381-388.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/20177043" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Getting%20to%20%E2%80%9Cno%E2%80%9D%3A%20strategies%20primary%20care%20physicians%20use%20to%20deny%20patient%20requests.&author=DA%20Paterniti&author=TL%20Fancher&author=CS%20Cipri&author=S%20Timmermans&author=J%20Heritage&author=RL%20Kravitz&publication_year=2010&journal=Arch%20Intern%20Med&volume=170&pages=381-388" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/archinternmed.2009.533" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/archinternmed.2009.533" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r7">7.</a><div class="reference-content">Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. <i xmlns:helper="urn:XsltStringHelper"> Ann Fam Med</i>. 2005;3(5):415-421.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/16189057" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Patient-centered%20communication%20and%20diagnostic%20testing.&author=RM%20Epstein&author=P%20Franks&author=CG%20Shields&publication_year=2005&journal=Ann%20Fam%20Med&volume=3&pages=415-421" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1370/afm.348" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1370/afm.348" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r8">8.</a><div class="reference-content">Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. <i xmlns:helper="urn:XsltStringHelper"> Cochrane Database Syst Rev</i>. 2012;12:CD003267.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/23235595" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Interventions%20for%20providers%20to%20promote%20a%20patient-centred%20approach%20in%20clinical%20consultations.&author=F%20Dwamena&author=M%20Holmes-Rovner&author=CM%20Gaulden&publication_year=2012&journal=Cochrane%20Database%20Syst%20Rev&volume=12&pages=CD003267" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a></div></div><div class="reference"><a class="reference-number" id="ioi150093r9">9.</a><div class="reference-content">Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P. Improving physicians’ HIV risk-assessment skills using announced and unannounced standardized patients. <i xmlns:helper="urn:XsltStringHelper"> J Gen Intern Med</i>. 2001;16(3):176-180.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/11318913" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Improving%20physicians%E2%80%99%20HIV%20risk-assessment%20skills%20using%20announced%20and%20unannounced%20standardized%20patients.&author=RM%20Epstein&author=JC%20Levenkron&author=L%20Frarey&author=J%20Thompson&author=K%20Anderson&author=P%20Franks&publication_year=2001&journal=J%20Gen%20Intern%20Med&volume=16&pages=176-180" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1111/j.1525-1497.2001.02299.x" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1111/j.1525-1497.2001.02299.x" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r10">10.</a><div class="reference-content">Jerant A, Kravitz RL, Azari R, et al. Training residents to employ self-efficacy-enhancing interviewing techniques: randomized controlled trial of a standardized patient intervention. <i xmlns:helper="urn:XsltStringHelper"> J Gen Intern Med</i>. 2009;24(5):606-613.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/19296179" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Training%20residents%20to%20employ%20self-efficacy-enhancing%20interviewing%20techniques%3A%20randomized%20controlled%20trial%20of%20a%20standardized%20patient%20intervention.&author=A%20Jerant&author=RL%20Kravitz&author=R%20Azari&publication_year=2009&journal=J%20Gen%20Intern%20Med&volume=24&pages=606-613" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1007/s11606-009-0946-4" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1007/s11606-009-0946-4" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r11">11.</a><div class="reference-content">Epstein RM, Street RL Jr. Shared mind: communication, decision making, and autonomy in serious illness. <i xmlns:helper="urn:XsltStringHelper"> Ann Fam Med</i>. 2011;9(5):454-461.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/21911765" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Shared%20mind%3A%20communication%2C%20decision%20making%2C%20and%20autonomy%20in%20serious%20illness.&author=RM%20Epstein&author=RL%20Street&publication_year=2011&journal=Ann%20Fam%20Med&volume=9&pages=454-461" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1370/afm.1301" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1370/afm.1301" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r12">12.</a><div class="reference-content">Charles C, Whelan T, Gafni A. What do we mean by partnership in making decisions about treatment? <i xmlns:helper="urn:XsltStringHelper"> BMJ</i>. 1999;319(7212):780-782.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/10488014" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=What%20do%20we%20mean%20by%20partnership%20in%20making%20decisions%20about%20treatment%3F&author=C%20Charles&author=T%20Whelan&author=A%20Gafni&publication_year=1999&journal=BMJ&volume=319&pages=780-782" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1136/bmj.319.7212.780" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1136/bmj.319.7212.780" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r13">13.</a><div class="reference-content">Stewart M, Ryan BL. <i xmlns:helper="urn:XsltStringHelper"> Assessing Communication Between Patients and Physicians: The Measure of Patient-Centered Communication (MPCC)</i>. London, Ontario, Canada: Thames Valley Family Practice Research Unit and Centre for Studies in Family Medicine; 2001.</div></div><div class="reference"><a class="reference-number" id="ioi150093r14">14.</a><div class="reference-content">Goertz M, Thorson D, Bonsell J, et al. Adult acute and subacute low back pain<i>.</i> Bloomington, MN: Institute for Clinical Systems Improvement. Updated November 2012. <a href="https://www.icsi.org/_asset/bjvqrj/LBP.pdf">https://www.icsi.org/_asset/bjvqrj/LBP.pdf</a>. Accessed September 7, 2015.</div></div><div class="reference"><a class="reference-number" id="ioi150093r15">15.</a><div class="reference-content">Florence R, Allen S, Benedict L, et al. Diagnosis and treatment of osteoporosis. Bloomington, MN: Institute for Clinical Systems Improvement. Updated July 2013. <a href="https://www.icsi.org/_asset/vnw0c3/Osteo.pdf">https://www.icsi.org/_asset/vnw0c3/Osteo.pdf</a>. Accessed September 7, 2015.</div></div><div class="reference"><a class="reference-number" id="ioi150093r16">16.</a><div class="reference-content">Gerrity MS, DeVellis RF, Earp JA. Physicians’ reactions to uncertainty in patient care: a new measure and new insights. <i xmlns:helper="urn:XsltStringHelper"> Med Care</i>. 1990;28(8):724-736.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/2385142" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Physicians%E2%80%99%20reactions%20to%20uncertainty%20in%20patient%20care%3A%20a%20new%20measure%20and%20new%20insights.&author=MS%20Gerrity&author=RF%20DeVellis&author=JA%20Earp&publication_year=1990&journal=Med%20Care&volume=28&pages=724-736" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1097/00005650-199008000-00005" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1097/00005650-199008000-00005" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r17">17.</a><div class="reference-content">Hade EM, Murray DM, Pennell ML, et al. Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies. <i xmlns:helper="urn:XsltStringHelper"> J Natl Cancer Inst Monogr</i>. 2010;2010(40):97-103.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/20386058" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Intraclass%20correlation%20estimates%20for%20cancer%20screening%20outcomes%3A%20estimates%20and%20applications%20in%20the%20design%20of%20group-randomized%20cancer%20screening%20studies.&author=EM%20Hade&author=DM%20Murray&author=ML%20Pennell&publication_year=2010&journal=J%20Natl%20Cancer%20Inst%20Monogr&volume=2010&pages=97-103" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1093/jncimonographs/lgq011" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1093/jncimonographs/lgq011" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r18">18.</a><div class="reference-content">Solomon DH, Hashimoto H, Daltroy L, Liang MH. Techniques to improve physicians’ use of diagnostic tests: a new conceptual framework. <i xmlns:helper="urn:XsltStringHelper"> JAMA</i>. 1998;280(23):2020-2027.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/9863854" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Techniques%20to%20improve%20physicians%E2%80%99%20use%20of%20diagnostic%20tests%3A%20a%20new%20conceptual%20framework.&author=DH%20Solomon&author=H%20Hashimoto&author=L%20Daltroy&author=MH%20Liang&publication_year=1998&journal=JAMA&volume=280&pages=2020-2027" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/jama.280.23.2020" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1001/jama.280.23.2020" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r19">19.</a><div class="reference-content">Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. <i xmlns:helper="urn:XsltStringHelper"> Radiology</i>. 2009;251(1):147-155.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/19221058" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Effect%20of%20computerized%20order%20entry%20with%20integrated%20decision%20support%20on%20the%20growth%20of%20outpatient%20procedure%20volumes%3A%20seven-year%20time%20series%20analysis.&author=CL%20Sistrom&author=PA%20Dang&author=JB%20Weilburg&author=KJ%20Dreyer&author=DI%20Rosenthal&author=JH%20Thrall&publication_year=2009&journal=Radiology&volume=251&pages=147-155" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1148/radiol.2511081174" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1148/radiol.2511081174" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r20">20.</a><div class="reference-content">Ip IK, Gershanik EF, Schneider LI, et al. Impact of IT-enabled intervention on MRI use for back pain. <i xmlns:helper="urn:XsltStringHelper"> Am J Med</i>. 2014;127(6):512-518.e1.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/24513065" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Impact%20of%20IT-enabled%20intervention%20on%20MRI%20use%20for%20back%20pain.&author=IK%20Ip&author=EF%20Gershanik&author=LI%20Schneider&publication_year=2014&journal=Am%20J%20Med&volume=127&pages=512-518.e1" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1016/j.amjmed.2014.01.024" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1016/j.amjmed.2014.01.024" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r21">21.</a><div class="reference-content">Martin AR, Wolf MA, Thibodeau LA, Dzau V, Braunwald E. A trial of two strategies to modify the test-ordering behavior of medical residents. <i xmlns:helper="urn:XsltStringHelper"> N Engl J Med</i>. 1980;303(23):1330-1336.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/7432374" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=A%20trial%20of%20two%20strategies%20to%20modify%20the%20test-ordering%20behavior%20of%20medical%20residents.&author=AR%20Martin&author=MA%20Wolf&author=LA%20Thibodeau&author=V%20Dzau&author=E%20Braunwald&publication_year=1980&journal=N%20Engl%20J%20Med&volume=303&pages=1330-1336" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1056/NEJM198012043032304" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1056/NEJM198012043032304" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r22">22.</a><div class="reference-content">Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. <i xmlns:helper="urn:XsltStringHelper"> N Engl J Med</i>. 2010;363(1):4-6.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/20573920" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=The%20uncritical%20use%20of%20high-tech%20medical%20imaging.&author=BJ%20Hillman&author=JC%20Goldsmith&publication_year=2010&journal=N%20Engl%20J%20Med&volume=363&pages=4-6" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1056/NEJMp1003173" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1056/NEJMp1003173" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r23">23.</a><div class="reference-content">Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. <i xmlns:helper="urn:XsltStringHelper"> Ann Intern Med</i>. 2015;162(2):100-108.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/25599349" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Overuse%20of%20testing%20in%20preoperative%20evaluation%20and%20syncope%3A%20a%20survey%20of%20hospitalists.&author=A%20Kachalia&author=A%20Berg&author=A%20Fagerlin&publication_year=2015&journal=Ann%20Intern%20Med&volume=162&pages=100-108" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.7326/M14-0694" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.7326/M14-0694" xmlns:helper="urn:XsltStringHelper"> </span></div></div><div class="reference"><a class="reference-number" id="ioi150093r24">24.</a><div class="reference-content">Srinivasan M, Franks P, Meredith LS, Fiscella K, Epstein RM, Kravitz RL. Connoisseurs of care? unannounced standardized patients’ ratings of physicians. <i xmlns:helper="urn:XsltStringHelper"> Med Care</i>. 2006;44(12):1092-1098.<a class="pubmed-link" href="https://www.ncbi.nlm.nih.gov/pubmed/17122713" target="_blank" xmlns:helper="urn:XsltStringHelper">PubMed</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Connoisseurs%20of%20care%3F%20unannounced%20standardized%20patients%E2%80%99%20ratings%20of%20physicians.&author=M%20Srinivasan&author=P%20Franks&author=LS%20Meredith&author=K%20Fiscella&author=RM%20Epstein&author=RL%20Kravitz&publication_year=2006&journal=Med%20Care&volume=44&pages=1092-1098" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1097/01.mlr.0000237197.92152.5e" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span class="inst-open-url-holders" data-targetId="10.1097/01.mlr.0000237197.92152.5e" xmlns:helper="urn:XsltStringHelper"> </span></div></div></div> </div> </div> <div class="movable-ad bta"> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_textbreak_bta_dual"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_textbreak_bta_dual" data-params="{"parameters":{"siteName":"jamainternalmedicine","siteId":15,"journalId":71,"adDisplay":8,"adSection":"textbreak","adPosition":"bta","fromGoogle":false},"dynamicParameters":{}}"></div> </div> </div> </div> </div> <div class="hidden-jobs-ad hide"> <div class="widget-WidgetLoader widget-instance-AMA_JobsAd"> <div class="SCM-SharedWidgets-AsyncJobsAdLoader" data-url="/AMA/JobsAd/AMA_JobsAd" data-params="{"parameters":{"SiteId":15},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <script> var App = App || {}; App.ArticleSplitScreen = App.ArticleSplitScreen || {}; App.ArticleSplitScreen.siteName = 'jamainternalmedicine'; App.ArticleSplitScreen.siteId = 15; App.ArticleSplitScreen.journalId = 71; App.ArticleSplitScreen.adDisplay = 'ArticleContentsSkyBox'; App.ArticleSplitScreen.adSection = "scholarly"; App.ArticleSplitScreen.adPosition = "contab"; App.ArticleSplitScreen.controlId = "AMA_AdTag_Contents_Skybox"; App.ArticleSplitScreen.fromGoogle = "False"; App.ArticleSplitScreen.slotLocationOverride = "50"; </script> </div> </div> </section> <section id="secFooterControl" class="master-footer"> <script> var App = App || {}; function scmByClass(className) { return document.getElementsByClassName(className); } function scmById(id) { return document.getElementById(id); } function scmquery(selector) { return document.querySelector(selector); } function queryAll(selector) { return document.querySelectorAll(selector); } function isTrueString(string) { if (typeof string === 'string') { return string.toLowerCase() === 'true'; } return undefined; } function updateViewportDimensions() { var w = window, d = document, e = d.documentElement, g = d.getElementsByTagName('body')[0], x = w.innerWidth || e.clientWidth || g.clientWidth, y = w.innerHeight || e.clientHeight || g.clientHeight; return { width: x, height: y }; } var viewport = updateViewportDimensions(); var debounce = function (func, wait, immediate) { var timeout; return function () { var context = this, args = arguments; var later = function () { timeout = null; if (!immediate) func.apply(context, args); }; var callNow = immediate && !timeout; clearTimeout(timeout); timeout = setTimeout(later, wait); if (callNow) func.apply(context, args); }; }; (function (App) { App.mobileUpperBreakpoint = 767; App.mobileAltBreakpoint = 640; App.mobileMinBreakpoint = 547; App.tabletUpperBreakpoint = 1023; function setVariables() { viewport = updateViewportDimensions(); App.isMobile = (viewport.width <= App.mobileUpperBreakpoint); App.isMobileAlt = (viewport.width <= App.mobileAltBreakpoint); App.isTablet = (viewport.width > App.mobileUpperBreakpoint && viewport.width <= App.tabletUpperBreakpoint); App.isTabletDown = (viewport.width <= App.tabletUpperBreakpoint); App.isDesktop = (viewport.width > App.tabletUpperBreakpoint); App.activeViewport = App.isMobile ? 'small' : App.isTablet ? 'med' : 'large'; } setVariables(); App.cachedViewport = App.isMobile ? 'small' : App.isTablet ? 'med' : 'large'; App.isAnyArticle = !!(scmByClass('widget-ArticleFullView').length || scmByClass('pg_abstract').length || scmByClass('widget-MagazineView').length || scmByClass('widget-ChannelsMagazineView').length); App.isSplitScreen = !!scmByClass('widget-ArticleFullView').length; App.isArticleRedesign = !!scmByClass('widget-ArticleWrapper').length; App.isAbstract = !!scmByClass('pg_abstract').length; App.isMag = !!(scmByClass('widget-MagazineView').length); App.isChannel = !!(scmByClass('channel-site').length); App.isChannelMag = !!(scmByClass('widget-ChannelsMagazineView').length); App.isFreeArticle = !!(scmquery('.widget-ArticleTopInfo .free-access') || scmquery('.widget-ArticleTopInfo .open-access') || scmquery('.widget-ArticleTopInfo .icon-free') || scmquery('.widget-ChannelsMagazineView .free-access')); App.isTollFreeAccess = false; App.isIssue = !!scmByClass('pg_issue').length || !!scmByClass('pg_newonline').length || !!scmByClass('pg_currentissue').length || !!scmByClass('pg_pastissues').length; App.isNewOnline = !!scmByClass('pg_newonline').length; App.isCurrentIssue = !!scmByClass('pg_currentissue').length; App.isPastIssues = !!scmByClass('pg_pastissues').length; App.isJournal = !!scmByClass('pg_journal').length; App.isNetworkHome = !!scmByClass('pg_index').length; App.isSearch = !!scmByClass('pg_searchresults').length; App.isAdvancedSearch = !!scmByClass('pg_advancedsearch').length; App.isPlayer= !!scmByClass('pg_multimediaplayer').length; App.isSelfServe = !!scmByClass('pg_sspage').length; App.isCmsPage = !!scmByClass('pg_cmspage').length; App.isMyAccount = !!scmByClass('pg_myaccount').length; App.supportsFlexbox = !!scmByClass('flexbox').length; App.isCollection = !!scmByClass('pg_collection').length; App.isPaidUser = isTrueString(scmById('hfAppIsPaidUser').getAttribute('value')); App.isMember = isTrueString(scmById('hfAppIsMember').getAttribute('value')); App.isIndividual = isTrueString(scmById('hfAppIsIndividual').getAttribute('value')); App.hasAccess = isTrueString(scmById('hfAppHasAccess').getAttribute('value')); App.isReferredFromGoogle = isTrueString(scmById('hfAppIsReferredFromGoogle').getAttribute('value')); var subscribedTo = scmById('hfAppSubscribedTo').getAttribute('value'); App.userSubscribedTo = subscribedTo ? subscribedTo.split(',') : undefined; App.isLucy = isTrueString(scmById('hfAppIsLucy').getAttribute('value')); App.currentJournalCount = 27; App.isChannelPage = !!(scmByClass('channels-page')); App.updateAppVariables = debounce(function () { setVariables(); }, 50, false); })(App); </script> <div class="footer-ad-wrapper"> <div id="BodyContent_Footer_divAds" class="footer-ad desktop-only"> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_AnchorboardAd_btf"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_AnchorboardAd_btf" data-params="{"parameters":{"siteName":"jamainternalmedicine","siteId":15,"journalId":71,"adDisplay":11,"adSection":"scholarly","adPosition":"btf","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> </div> <div class="ad-riser-wrap desktop-only"> <div class="ad-riser--dismiss t-c">X</div> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_Riser"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_Riser" data-params="{"parameters":{"siteName":"jamainternalmedicine","siteId":15,"journalId":71,"adDisplay":12,"adSection":"scholarly","adPosition":"Riser","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div class="footer-wrap"> <footer class="footer" id="footer"> <div id="footer-microsite" class="footer-microsite"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Left" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> @media (min-width: 1024px) {.split-screen .footer-microsite-contents {border-bottom:0 !important;}} .footer-microsite-contents {margin-bottom:1em;width:100%;} .footer-network-other .link-apps:before {width: 23px;} .footer-network-other .link-institutions-librarians:before {width: 23px;} .jn-ss-footer-border-top {border-top:1px solid #555;padding-top:15px;} .jn-ss-footer-border-bottom {border-bottom:1px solid #555;padding-bottom:10px;padding-right:5px;} </style> <div class="footer-heading-wrap"> <h3 id="BodyContent_Footer_h3SiteName" class="footer-heading is-b footer-microsite-heading" data-mobile-tog-target=".footer-microsite-links-wrap">JAMA Internal Medicine</h3> </div> <div class="footer-microsite-links-wrap"> <div class="footer-microsite-contents jn-ss-footer-border-bottom"> <h4 id="BodyContent_Footer_ContentHeader" class="footer-subheading">Content</h4> <a href="/journals/jamainternalmedicine">Home</a> <a href="/journals/jamainternalmedicine/newonline">New Online</a> <a href="/journals/jamainternalmedicine/currentissue">Current Issue</a> </div> <div class="footer-microsite-contents jn-ss-footer-border-bottom"> <h4 class="footer-subheading">Podcast</h4> <a href="/journals/jamainternalmedicine/pages/jama-internal-medicine-author-interviews">JAMA Internal Medicine Author Interviews</a> </div> <div class="footer-microsite-services cf"> <h4 id="BodyContent_Footer_ServiceHeader" class="footer-subheading">Journal Information</h4> <a href="/journals/jamainternalmedicine/pages/for-authors">For Authors</a> <a href="/journals/jamainternalmedicine/editors-and-publishers">Editors & Publishers</a> <a href="/pages/rss">RSS</a> <a href="/journals/jamainternalmedicine/pages/contact-us">Contact Us</a> </div> <div class="footer-network-other jn-ss-footer-border-bottom"> <a href="https://edhub.ama-assn.org/jn-learning" class="link-network-other is-b link-learning">JN Learning / CME</a> <a href="https://store.jamanetwork.com" class="link-network-other is-b link-store" target="_blank">Store</a> <a href="/pages/apps" class="link-network-other is-b link-mobile" target="_blank">Apps</a> <a href="https://careers.jamanetwork.com/" class="link-network-other is-b link-jobs" target="_blank">Jobs</a> <a href="/pages/resources-for-librarians" class="link-network-other is-b link-institutions-librarians" target="_blank">Institutions</a> <a href="/pages/reprints-and-permissions" class="link-network-other is-b link-reprints-permissions">Reprints & Permissions</a> </div> <div id="BodyContent_Footer_divSubscribe" class="footer-microsite-subscribe"> <img src="//cdn.jamanetwork.com/UI/app/img/covers/intem.jpg" class="subscribe-image" alt="Journal Cover"> <div class="subscribe-meta"> <h4 class="subscribe-heading footer-subheading">Subscribe</h4> <a href="https://store.jamanetwork.com/productDetails.aspx?productcodeID=56" class="subscribe-submit btn">Go</a> </div> </div> </div> </div> <div id="footer-network" class="footer-network"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Middle" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .footer-network-sites {width: 62.85542%;} .footer-network-info {width: 35.93976%} .jn-ss-subheading-mt {margin-top: 1.5em;} .jn-registered:after {content: "\00AE";font-size: 50%;vertical-align: top;} .jn-trademark:after {content: "\2122";font-size: 50%;vertical-align: top;} .nav-logo-cme-signin-container .nav-logo .site-logo img { min-width:50px;} </style> <div class="footer-heading-wrap"> <h3 class="footer-heading is-b jn-registered" data-mobile-tog-target=".footer-network-links-wrap"><strong>JAMA</strong> Network</h3> </div> <div class="footer-network-links-wrap"> <div class="footer-network-sites"> <div class="internal"> <h4 id="BodyContent_Footer_JournalHeader" class="footer-subheading">Publications</h4> <a href="/journals/jama">JAMA</a> <a href="/journals/jamanetworkopen" target="_blank">JAMA Network Open</a> <a href="/journals/jamacardiology">JAMA Cardiology</a> <a href="/journals/jamadermatology">JAMA Dermatology</a> <a href="/journals/jama-health-forum">JAMA Health Forum</a> <a href="/journals/jamainternalmedicine">JAMA Internal Medicine</a> <a href="/journals/jamaneurology">JAMA Neurology</a> <a href="/journals/jamaoncology">JAMA Oncology</a> <a href="/journals/jamaophthalmology">JAMA Ophthalmology</a> <a href="/journals/jamaotolaryngology">JAMA Otolaryngology–Head & Neck Surgery</a> <a href="/journals/jamapediatrics">JAMA Pediatrics</a> <a href="/journals/jamapsychiatry">JAMA Psychiatry</a> <a href="/journals/jamasurgery">JAMA Surgery</a> <a href="/journals/archneurpsyc">Archives of Neurology & Psychiatry (1919-1959)</a> </div> <div class="external"> <h4 class="footer-subheading">Sites</h4> <div id="BodyContent_Footer_ssFooterSiteMenu"> <div class="selfServe"> <a target="_blank" href="https://sites.jamanetwork.com/art-and-images-in-psychiatry/">Art and Images in Psychiatry</a> <a target="_blank" href="/journals/jama/pages/2023-most-viewed-jama">Best of the JAMA Network</a> <a target="_blank" href="/channels/caring-for-the-critically-ill-patient">Caring for the Critically Ill Patient</a> <a target="_blank" href="/journals/jama/pages/crosswords">Clinical Crosswords from JAMA</a> <a target="_blank" href="/journals/jama/pages/coronavirus-alert">Coronavirus Resource Center</a> <a target="_blank" href="https://ebm.jamanetwork.com/index.html">Evidence-Based Medicine: An Oral History</a> <a target="_blank" href="/pages/fishbein-fellowship">Fishbein Fellowship</a> <a target="_blank" href="/channels/genomics/">Genomics and Precision Health</a> <a target="_blank" href="/pages/health-and-the-2024-us-election">Health and the 2024 US Election</a> <a target="_blank" href="/channels/hypertension">Hypertension</a> <a target="_blank" href="/channels/health-forum/archive">JAMA Forum Archive</a> <a target="_blank" href="https://sites.jamanetwork.com/audio">JAMA Network Audio</a> <a target="_blank" href="/pages/video">JAMA Network Video</a> <a target="_blank" href="/pages/conferences">JAMA Network Conferences </a> <a target="_blank" href="/channels/ai">JAMA+ AI</a> <a target="_blank" href="/pages/jama-summit">JAMA Summit </a> <a target="_blank" href="/journals/jamasurgery/pages/statistics-and-methods">JAMA Surgery Guide to Statistics and Methods</a> <a target="_blank" href="/channels/medical-news">Medical News</a> <a target="_blank" href="/channels/monkeypox">Mpox (Monkeypox)</a> <a target="_blank" href="https://sites.jamanetwork.com/research-ethics/">Research Ethics</a> <a target="_blank" href="/pages/collections">Topics and Collections</a> <a target="_blank" href="/pages/visual-abstracts">Visual Abstracts</a> <a target="_blank" href="/channels/war">War and Health</a> <a target="_blank" href="/channels/womens-health">Women's Health</a> <h4 class="footer-subheading jn-ss-subheading-mt">Featured Articles</h4> <a href="/journals/jama/fullarticle/2781397">CONSERVE 2021 Guidelines for Reporting Trials Modified for the COVID-19 Pandemic</a> <a href="/journals/jama/fullarticle/2808296">Creation and Adoption of Large Language Models in Medicine</a> <a href="/journals/jamaoncology/fullarticle/2787350">Global Burden of Cancer, 2010-2019</a> <a href="/journals/jama/fullarticle/2797443">Global Burden of Long COVID</a> <a href="/journals/jamadermatology/fullarticle/2790344">Global Burden of Melanoma</a> <a href="/journals/jamadermatology/fullarticle/2787350">Global Burden of Skin Diseases, 1990-2017</a> <a href="/journals/jamaneurology/fullarticle/2793874">Global Disparities in Parkinson Disease</a> <a href="/journals/jama/fullarticle/2799547">Guidelines for Reporting Outcomes in Trial Protocols: The SPIRIT-Outcomes 2022 Extension</a> <a href="/journals/jamapsychiatry/fullarticle/2799486">Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning</a> <a href="/journals/jamapsychiatry/fullarticle/2793903">Neuropsychiatry Sequelae of COVID-19</a> <a href="/journals/jamaneurology/fullarticle/2810313">A New Framework for Dementia Nomenclature</a> <a href="/journals/jama/fullarticle/2800656">Organization and Performance of US Health Systems</a> <a href="/journals/jama-health-forum/fullarticle/2791195">Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy</a> <a href="/journals/jama-health-forum/fullarticle/2791195">Promoting EDI in Genetics Research</a> <a href="/journals/jamacardiology/fullarticle/2781972">PTSD and Cardiovascular Disease</a> <a href="/journals/jama/fullarticle/2810754">Red Blood Cell Transfusion: 2023 AABB International Guidelines</a> <a href="/journals/jamapediatrics/fullarticle/2797600">Reimagining Children’s Rights in the US</a> <a href="/journals/jama/fullarticle/2794049">Spirituality in Serious Illness and Health</a> <a href="/journals/jama/fullarticle/2796374">The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity</a> <h4 class="footer-subheading jn-ss-subheading-mt">USPSTF Recommendation Statements</h4> <a href="/journals/jama/fullarticle/2779985">Screening for Colorectal Cancer</a> <a href="/journals/jama/fullarticle/2779190">Screening for Hypertension</a> <a href="/journals/jama/fullarticle/2777244">Screening for Lung Cancer</a> <a href="/journals/jama/fullarticle/2796244">Screening for Prediabetes and Type 2 Diabetes In Children</a> <a href="/journals/jama/fullarticle/2783414">Screening for Prediabetes and Type 2 Diabetes In Adults</a> <a href="/journals/jama/fullarticle/2795521">Statins for Primary Prevention of Cardiovascular Disease</a> <a href="/journals/jama/fullarticle/2793446">Vitamin and Mineral Supplements for Primary Prevention of of Cardiovascular Disease and Cancer</a> <h4 class="footer-subheading jn-ss-subheading-mt">Blogs</h4> <a target="_blank" href="https://amastyleinsider.com/">AMA Style Insider</a> </div> </div> </div> </div> <div id="footer-network-info" class="footer-network-info"> <div class="information-for-links"> <h4 id="BodyContent_Footer_InfoHeader" class="footer-subheading">Information</h4> <a href="/pages/for-authors">For Authors</a> <a href="/pages/resources-for-librarians">For Institutions & Librarians</a> <a href="/pages/advertisers">For Advertisers</a> <a href="/pages/subscription-agents">For Subscription Agents</a> <a href="https://careers.jamanetwork.com/" target="_blank">For Employers & Job Seekers</a> <a href="https://media.jamanetwork.com" rel="nofollow" target="_blank">For the Media</a> <a href="/pages/equity-diversity-inclusion">Equity, Diversity, Inclusion</a> <a href="/pages/commenting-policy">Online Commenting Policy</a> <a href="/pages/access-at-jama-network">Public Access and Open Access Policy</a> <a href="/pages/offensive-content-statement">Statement on Potentially Offensive Content</a> </div> <div class="services-links"> <h4 id="BodyContent_Footer_JAMANetworkProductsHeader" class="footer-subheading">JAMA Network Products</h4> <a href="http://www.amamanualofstyle.com/" class="footer-service-link" target="_blank">AMA Manual of Style</a> <a href="https://jamaevidence.mhmedical.com/" class="footer-service-link" target="_blank"><span class="jn-registered">JAMAevidence</span></a> <a href="http://www.peerreviewcongress.org/" class="footer-service-link" target="_blank">Peer Review Congress</a> </div> <div class="learning-links"> <h4 id="BodyContent_Footer_LearningHeader" class="footer-subheading">JN Learning</h4> <a href="https://edhub.ama-assn.org/jn-learning">Home</a> <a href="https://edhub.ama-assn.org/jn-learning/state-cme">State CME</a> <a href="https://edhub.ama-assn.org/jn-learning/pages/clinical-challenge-courses">Clinical Challenge CME</a> <a href="https://edhub.ama-assn.org/jn-learning/course/288 ">Atrial Fibrillation Course</a> <a href="https://edhub.ama-assn.org/jn-learning/course/294 ">Women's Health Course</a> <a target="_blank" href="https://edhub.ama-assn.org/pages/auto-credit-reporting">CME / MOC Reporting Preferences</a> <a href="https://edhub.ama-assn.org/jn-learning/pages/about-cme">About CME & MOC</a> </div> </div> </div> </div> <div id="footer-resources-wrap" class="footer-resources-wrap"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Right" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .footer-resources-wrap .footer-subheading {color: grey;display:block !important;font-size: 1.17647em;font-weight: 400;text-transform: uppercase;} </style> <div class="footer-heading-wrap"> <h3 class="footer-heading is-b footer-resources-heading" data-mobile-tog-target=".footer-resources">Help</h3> </div> <div class="footer-resources"> <a href="https://store.jamanetwork.com" class="footer-service-link" target="_blank">Subscriptions & Renewals</a> <a href="https://jamanetwork.com/oauthsignin?return_url=http%3A%2F%2Fjamanetwork.com%2Fmyaccount%23my-alerts" class="footer-service-link" rel="nofollow">Manage Emails</a> <a href="https://jamanetwork.com/oauthsignin?return_url=http%3A%2F%2Fjamanetwork.com%2Fmyaccount%23my-profile" class="footer-service-link" rel="nofollow">Update My Address</a> <a href="https://support.jamanetwork.com/hc/en-us" class="footer-service-link">Support Center</a> <a href="/myaccount " class="footer-service-link">My Account</a> <h4 class="footer-subheading jn-ss-subheading-mt">JAMA Career Center</h4> <a href="https://careers.jamanetwork.com/" class="footer-service-link" target="_blank">Physician Job Listings</a> </div> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Socials" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .widget-instance-AMA_Journal_Home_Socials .iconsocial {display: inline-block !important;width: 34px;height: 34px;min-width: unset !important;margin: 0 2px !important;background-color: #fff;border-radius: 20px;border: 1px solid #191919;vertical-align: middle;} .widget-instance-AMA_Journal_Home_Socials .iconsocial.instagram {background-image: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-black.svg);background-position: 7px 7px;background-repeat: no-repeat;background-size: 18px;} .widget-instance-AMA_Journal_Home_Socials .iconsocial.instagram:hover, .widget-instance-AMA_Journal_Home_Socials .iconsocial.instagram:focus {background-image: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-fill.png);border-color: #C13584;} .footer-resources-wrap .iconsocial {display: inline-block !important;width: 32px;height: 32px;min-width: unset !important;margin: 0 2px 0 3px !important;background-color: #fff;border-radius: 20px;border: 1px solid #191919;vertical-align: middle;} .footer-resources-wrap .iconsocial.instagram {background-image: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-black.svg);background-position: 6px 6px;background-repeat: no-repeat;background-size: 18px;} .footer-resources-wrap .iconsocial.instagram:hover, .footer-resources-wrap .iconsocial.instagram:focus {background-color: #C13584;border-color: #191919;} #load-instagram-image { background: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-fill.png) no-repeat -9999px -9999px; } </style> <div id="BodyContent_Footer_divSocial" class="social-links footer-social-links"> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="https://www.facebook.com/jamainternalmedicine/" class="social-link is-b facebook"></a> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="https://twitter.com/JAMAInternalMed" class="social-link is-b twitter"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://www.instagram.com/jamanetwork/?hl=en" class="iconsocial instagram"></a> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="https://www.linkedin.com/showcase/jamainternalmedicine/" class="social-link is-b linked-in"></a> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="https://ja.ma/imdyt" class="social-link is-b you-tube"></a> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="https://www.pinterest.com/jamanetwork/" class="social-link is-b pinterest"></a> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="/rss/site_15/71.xml" class="social-link is-b rss"></a> <a target="_blank" rel="nofollow" data-emailid="2510b734-557b-4482-a469-c616867db663" href="https://jamanetwork.com/journals/jamainternalmedicine/pages/jama-internal-medicine-author-interviews" class="social-link is-b podcast"></a> <div id="load-instagram-image"></div> </div> <div id="BodyContent_Footer_divEmailUpdate" class="footer-email-updates"> <div class="widget-EmailListSignUp widget-instance-AMAv2_EmailListSignUp_Footer"> <div class="email-signup"> <div class="email-signup--text sb-pc">Get the latest from JAMA Internal Medicine</div> <div class="email-signup--input-wrap is-b"> <input type="text" name="email" class="email-signup--input" placeholder="Email address" title="Email address" /> <a rel="nofollow" href="javascript:;" class="email-signup--submit sb-sc btn">Sign Up</a> </div> <div class="email-signup--link"> <a class="email-signup--privacy" href="/pages/privacy-policy">Privacy Policy</a> | <a class="email-signup--terms" href="/pages/terms-of-use">Terms of Use</a></div> <div class="email-signup--user-message"></div> </div> </div> </div> </div> <div class="footer-bar" itemscope itemtype="https://schema.org/Organization"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Bottom_Bar" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .network-bar .auth--inst {color:#B8B8B8;} .multimedia-caption-container div.video-caption {color: #262626;font-size: 15px;font-weight: 700;line-height: 1.5;} .nav-journals a.theme-jama-health-forum:before {background: #133763;} .jn-bottom-bar {color: #fff; float: left;font-size: 10px;padding: 13px 20px;width: 33.33%;} .jn-bottom-bar p {line-height: 2;} @media (max-width: 900px) {.jn-bottom-bar {float: none;width: 100%;}} .jn-footer-copyright {font-size:12px;line-height:1.5;margin-bottom:10px;} .jn-footer-pipe {margin:0 10px;} .footer-bar-jn-logo img {width: 230px;} @media (max-width: 900px) {.footer-bar-jn-logo img {width: 200px;}} [data-thm=umb] .jobs-ad--text h6 {color: #d71635 !important;} [data-thm=jama] .jobs-ad--text h6 {color: #d71635 !important;} [data-thm=jaman] .jobs-ad--text h6 {color: #ed0973 !important;} [data-thm=cardi] .jobs-ad--text h6 {color: #be1e32 !important;} [data-thm=derm] .jobs-ad--text h6 {color: #006f3b !important;} [data-thm=faci] .jobs-ad--text h6 {color: #ed1c24 !important;} [data-thm=jama-] .jobs-ad--text h6 {color: #fb5252 !important;} [data-thm=intem] .jobs-ad--text h6 {color: #006e96 !important;} [data-thm=neur] .jobs-ad--text h6 {color: #981b1e !important;} [data-thm=oncol] .jobs-ad--text h6 {color: #3b923f !important;} [data-thm=ophth] .jobs-ad--text h6 {color: #66bc29 !important;} [data-thm=otol] .jobs-ad--text h6 {color: #34b6e4 !important;} [data-thm=peds] .jobs-ad--text h6 {color: #0084c0 !important;} [data-thm=psych] .jobs-ad--text h6 {color: #005276 !important;} [data-thm=surg] .jobs-ad--text h6 {color: #f47920 !important;} .blockquote .para {margin: 0 0 1em 1em;} .jn-footer-copyright {display: block;} .inline-block {display: inline-block;} </style> <a class="footer-bar-jn-logo d-b no-mw mb1" href="/" title="JAMA Network Home"><img class="mw-100" src="https://cdn.jamanetwork.com/ImageLibrary/global/jn-signature-reversed-r.svg?versionId=82308" alt="Jama Network Logo"></a> <div class="jn-bottom-bar"> <p> <span class="jn-footer-copyright">© 2024 American Medical Association. <span class="inline-block">All rights reserved,</span> including those for text and data mining, AI training, <span class="inline-block">and similar technologies.</span></span> <span class="inline-block"><a href="https://www.ama-assn.org/about/terms-use" rel="nofollow" class="p0">Terms of Use</a><span class="jn-footer-pipe">|</span></span> <span class="inline-block"><a href="https://www.ama-assn.org/about/privacy-policy" rel="nofollow" class="p0">Privacy Policy</a><span class="jn-footer-pipe">|</span></span> <span class="inline-block"><a href="https://www.ama-assn.org/about/accessibility-statement" rel="nofollow" class="p0">Accessibility Statement</a><span class="jn-footer-pipe">|</span></span> <span class="inline-block"><a onclick="OneTrust.ToggleInfoDisplay()" rel="nofollow" class="p0" id="CookieFooter">Cookie Settings</a></span> </p> </div>  <a class="footer-bar-sis no-mw relative nudge-down" href="https://www.silverchair.com" target="_blank"><img class="footer-bar-sis-img mt05 mw-100" width="600" height="70" src="//cdn.jamanetwork.com/UI/app/img/powered.png" alt="Silverchair Logo" /></a> </div> </footer> </div> <div class="ss-ui-only"> <div class="widget-SelfServeContent widget-instance-AMA_SS_UI_Only"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SsUiOnly" /> <input type="hidden" class="SelfServeVersionId" value="0" /> . </div> </div> </div> </section> <div id="revealModal" class="reveal-modal" data-reveal> <div id="revealContent"></div> <a class="close-reveal-modal icon-close"></a> </div> <div class="artmet-modal" id="MetricsModal"> <div class="artmet-modal-contents"> <a class="artmet-close-modal">×</a> </div> </div> <div class="widget-SigninModals widget-instance-AMA_SigninModals"> <div class="js-modal-no-access-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Access your subscriptions</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_NoAccess_AdvancedSeamlessAccessButton"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_NoAccess_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_NoAccess_SigninModal_PurchaseOptions_NoAccessAndPaidPDF"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_NoAccessAndPaidPDF" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Purchase access</div> <hr> <button class="modal--btn js-btn-subscribe-journal" type="button" role="button"> <div class="text-truncate">Subscribe to journal</div> </button> <div class="modal--btn-desc">Get full journal access for 1 year</div> <button class="modal--btn js-btn-purchase-article" type="button" role="button"> <div class="text-truncate">Buy article</div> </button> <div class="modal--btn-desc">Get unlimited access and a printable PDF ($40.00)—<br> <em>Sign in or create a free account</em></div>  </div> </div> <div class="widget-DeepDyve widget-instance-AMA_NoAccess_DeepDyve"> <button type="button" role="button" class="modal--btn js-deepdyve-link hiddenRentalLink" data-deepdyveurl="https://www.deepdyve.com/doc-view?docId=10.1001/jamainternmed.2015.6840&fieldName=journal_doi&affiliateId=JAMA" data-doi="10.1001/jamainternmed.2015.6840" data-fieldname="journal_doi" data-issneissn="2168-6106" data-affiliate="JAMA">Rent article</button> <div class="modal--btn-desc js-deepdyve-desc hiddenRentalLink">Rent this article from DeepDyve</div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-paid-pdf-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Access your subscriptions</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_PaidPdf_AdvancedSeamlessAccessButton"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_PaidPdf_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_PaidPdf_SigninModal_PurchaseOptions_NoAccessAndPaidPDF"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_NoAccessAndPaidPDF" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Purchase access</div> <hr> <button class="modal--btn js-btn-subscribe-journal" type="button" role="button"> <div class="text-truncate">Subscribe to journal</div> </button> <div class="modal--btn-desc">Get full journal access for 1 year</div> <button class="modal--btn js-btn-purchase-article" type="button" role="button"> <div class="text-truncate">Buy article</div> </button> <div class="modal--btn-desc">Get unlimited access and a printable PDF ($40.00)—<br> <em>Sign in or create a free account</em></div>  </div> </div> <div class="widget-DeepDyve widget-instance-AMA_PaidPDF_DeepDyve"> <button type="button" role="button" class="modal--btn js-deepdyve-link hiddenRentalLink" data-deepdyveurl="https://www.deepdyve.com/doc-view?docId=10.1001/jamainternmed.2015.6840&fieldName=journal_doi&affiliateId=JAMA" data-doi="10.1001/jamainternmed.2015.6840" data-fieldname="journal_doi" data-issneissn="2168-6106" data-affiliate="JAMA">Rent article</button> <div class="modal--btn-desc js-deepdyve-desc hiddenRentalLink">Rent this article from DeepDyve</div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-free-pdf-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Sign in to access free PDF</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_FreePdf_AdvancedSeamlessAccessButton"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_FreePdf_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-save-search-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Save your search</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-SelfServeContent widget-instance-AMA_SaveSearch_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_SigninModal_PurchaseOptions_SaveSearch"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_SaveSearch" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Purchase access</div> <hr /> <button class="modal--btn js-btn-subscribe-now">Subscribe now</button>  </div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-follow-collection-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Customize your interests</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-SelfServeContent widget-instance-AMA_FollowCollection_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_SigninModal_PurchaseOptions_FollowCollection"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_FollowCollection" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--sub-title">Create a personal account or sign in to:</div> <ul> <li>Register for email alerts with links to free full-text articles</li> <li>Access PDFs of free articles</li> <li>Manage your interests</li> <li>Save searches and receive search alerts</li> <ul>  </div> </div> <div class="modal--link-wrap"> <a class="modal--link" href="/pages/privacy-policy" rel="nofollow">Privacy Policy</a> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-user-comment-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Make a comment</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjamainternalmedicine%2ffullarticle%2f2472948"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-SelfServeContent widget-instance-AMA_UserComment_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_SigninModal_PurchaseOptions_UserComment"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_UserComment" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--sub-title">Create a personal account or sign in to:</div> <ul> <li>Register for email alerts with links to free full-text articles</li> <li>Access PDFs of free articles</li> <li>Manage your interests</li> <li>Save searches and receive search alerts</li> <ul>  </div> </div> <div class="modal--link-wrap"> <a class="modal--link" href="/pages/privacy-policy" rel="nofollow">Privacy Policy</a> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="hidden-true js-modal-page-data" data-store-url="https://store.jamanetwork.com" data-store-purchase-url="https://jamanetwork.com/oauthsignin?return_url=https://store.jamanetwork.com" data-store-subscribe-url="https://store.jamanetwork.com/index.aspx?productcode=56"> </div> </div> <script src="//cdn.jamanetwork.com/UI/app/vendor/jquery-2.2.4.min.js?v=638654734634555810"></script> <script>window.jQuery || document.write('<script src="/UI/app/vendor/jquery-2.2.4.min.js">\x3C/script>')</script> <script src="//cdn.jamanetwork.com/UI/app/dist/app.min.js?v=638677764559592887" defer></script> <script src="//cdn.jsdelivr.net/chartist.js/latest/chartist.min.js" type="text/javascript"></script> <script src="//d1bxh8uas1mnw7.cloudfront.net/assets/embed.js" type="text/javascript"></script> <script defer src='//js.trendmd.com/trendmd.min.js' data-trendmdconfig='{"element":"#trendmd-suggestions"}'></script> <script type='text/javascript' src='https://platform-api.sharethis.com/js/sharethis.js#property=643701de45aa460012e1032e&product=sop' async='async'></script> <script> var App = App || {}; App.showCmePromo = false; </script> </form> <link rel="stylesheet" href="//cdn.jamanetwork.com/UI/app/scss/modules/_trendMD.css"> <div class="widget-CustomJSScript widget-instance-"> <script src="//cdn.jamanetwork.com/ama/ama.proxylogging.js" async></script> </div> </body> </html>

CINXE.COM

Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial | Radiology | JAMA Internal Medicine | JAMA Network