The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care

Figures & data

Table 1. Overview of general characteristics of the Dutch health care system

Structure of Dutch health care system
Basic insurance is obligatory for every citizen
Payment through monthly fee and wage taxes (employer)
Additional insurance coverage is voluntary
Primary care is 100% covered
Out-of-pocket payment for basic care is capped at €385^a
Academic and nonacademic hospitals

^aUnless citizens choose a higher threshold (max €850) for out-of-pocket payment in return for lower monthly fees.

Table 2. Overview of general characteristics of Dutch medical education continuum

Structure of Dutch Medical Education Continuum		Qualification After Graduation
Three Years Preclinical Training, Bachelor of Medicine
Three Years Clinical Training, Master of Medicine		Physician, M.D.
Intern Year (Can Be More Than 1 Year)	optional
Three to 6 Years of Residency Training (After Application and Selection Process)		Medical specialist

Table 3. Characteristics of focus group participants

		Years of Residency Training
Type of Specialty Training (Duration of Residency Program)	ParticipantsN (%)	M	Spread	Modus	M Years of Clinical Working Experience Preresidency^a
Dermatology (6 Years)	5	3	1–4	3	2
Elderly Care Medicine (3 Years)	8	3	3	3	2
Family Care Medicine (3 Years)	5	3	3	3	1
Internal Medicine (6 Years)	6	2	1–5	1	1
Orthopedic Surgery (6 Years)	6	4	2–6	5	0
Surgery (6 Years)	6	4	2–6	4	Unknown
Total Number of Participants	36
Characteristics of Participants
Final Year	15 (42%)
> 50% of Training Completed	23 (64%)
First Year of Training	13 (36%)
Female	23 (64%)
Male	13 (36%)

^aIn the Netherlands, there are opportunities to work in a healthcare institution (generally teaching or nonteaching hospital) after graduating medical school (M.D.) and before formally entering a residency program. This type of clinical working experience does not require formal teaching and is supervised by senior physicians.

Table

The questions	Moderator’s role	List of topics	Theoretical framework	Time (min)
Would you like to introduce yourself?	I/L lets every-one take a turn	Year of training Previous workplace, academic / peripheral		5
What is HV3C? 1) What do you think of HV3C?	I/L invites all to share ideas I/L summarize the ideas	What is the role of the patient in HV3C? What is the doctor’s role? What is the role of the organization?		15
High-value, cost-conscious care is a broad concept. We would like to discuss with you HV3C; HV3C refers to care that aims to assess the benefits, harms, and costs of interventions and consequently to provide care that adds value. The main focus today is on delivering HV3C to patients, the kind of care in which you, the doctors, play a vital role.
When do you come across HV3C in daily practice? 2a) On a normal working day, when would you be giving HV3C? 2b) And how?	I/L collects instances of HV3C			20
How do you learn to give HV3C? 3a) What do you consider when you are concerned with HV3C?	I/L ensures that everyone has their say I/L broadens the discussion with in-depth questions	3b) Where or from whom did you learn to deliver HV3C? 3c) What made you aware of things to do with HV3C? In or outside the hospital / work-related or private	Awareness of HV3C
		3d) What information or knowledge do you need for this? What do you consider when you make a decision in light of HV3C? - Patient preferences - Knowledge of best practice / EBM - Knowledge of costs / insurance Where did you obtain that knowledge?	Knowledge transfer
		3e) Do you ever look back on your actions from the standpoint of HV3C? What triggered you to reflect on your actions in the light of HV3C?	Reflection on action taken in practice
		3f) What role does HV3C play in the department and during supervision moments? 3g) Have you seen differences between different hospitals? Academic Peripheral Where do you think those differences come from?	Micro Stimulating environment Macro Stimulating environment
What do you need in your daily practice to ensure HV3C? What do you need to decide what kind of care would be considered HV3C in daily practice?	Closing questions
Is there anything left that we haven’t dealt with sufficiently? What else do you think is important to share with the group? What (else) do you need to deliver HV3C?	I/L ensures that everyone gets a chance to have their own say

Table

Topic	Item No.	Guide Questions/Description	Reported on Page No.
Domain 1: Research team and reflexivity
Personal characteristics
Interviewer/facilitator	1	Which author/s conducted the interview or focus group?	Page 5
Credentials	2	What were the researcher’s credentials? E.g. PhD, MD	Page 6
Occupation	3	What was their occupation at the time of the study?	Page 6
Gender	4	Was the researcher male or female?	n/a
Experience and training	5	What experience or training did the researcher have?	n/a
Relationship with participants
Relationship established	6	Was a relationship established prior to study commencement?	Page 4
Participant knowledge of the interviewer	7	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research	Appendix 1
Interviewer characteristics	8	What characteristics were reported about the inter viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic	Page 6
Domain 2: Study design
Theoretical framework
Methodological orientation and Theory	9	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis	Page 5
Participant selection
Sampling	10	How were participants selected? e.g. purposive, convenience, consecutive, snowball	Page 4
Method of approach	11	How were participants approached? e.g. face-to-face, telephone, mail, email	Page 4
Sample size	12	How many participants were in the study?	Page 4
Non-participation	13	How many people refused to participate or dropped out? Reasons?	Page 4
Setting
Setting of data collection	14	Where was the data collected? e.g. home, clinic, workplace	Page 4
Presence of nonparticipants	15	Was anyone else present besides the participants and researchers?	Page 5
Description of sample	16	What are the important characteristics of the sample? e.g. demographic data, date	Page 4
Data collection
Interview guide	17	Were questions, prompts, guides provided by the authors? Was it pilot tested?	Page 3, Appendix 1
Repeat interviews	18	Were repeat inter views carried out? If yes, how many?	Page 5
Audio/visual recording	19	Did the research use audio or visual recording to collect the data?	Page 5
Field notes	20	Were field notes made during and/or after the inter view or focus group?	Page 5
Duration	21	What was the duration of the inter views or focus group?	Page 4
Data saturation	22	Was data saturation discussed?	Page 5
Transcripts returned	23	Were transcripts returned to participants for comment and/or	n/a
Topic	Item No.	Guide Questions/Description	Reported on Page No.
		correction?
Domain 3: analysis and findings
Data analysis
Number of data coders	24	How many data coders coded the data?	Page 5, e-appendix 2
Description of the coding tree	25	Did authors provide a description of the coding tree?	n/a
Derivation of themes	26	Were themes identified in advance or derived from the data?	Page 5
Software	27	What software, if applicable, was used to manage the data?	Page 5
Participant checking	28	Did participants provide feedback on the findings?	n/a
Reporting
Quotations presented	29	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number	Page 6-12
Data and findings consistent	30	Was there consistency between the data presented and the findings?
Clarity of major themes	31	Were major themes clearly presented in the findings?
Clarity of minor themes	32	Is there a description of diverse cases or discussion of minor themes?

Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357.

Once you have completed this checklist, please save a copy and upload it as part of your submission. DO NOT include this checklist as part of the main manuscript document. It must be uploaded as a separate file.