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Academic Medicine, Vol. 95, No. 12 / December 2020 1900 Research Report Overuse of health care services represents a major source of wasted health care spending in the United States and is increasingly recognized as a problem worldwide. 1 Overuse includes services for which no medical basis exists, that can harm patients, and/or that may pose risks that exceed benefits. 2,3 Providing such services not only threatens the financial sustainability of health care systems but also exposes patients to unnecessary risks, 4 generates burdensome out-of-pocket expenses, 5,6 contributes to undue anxiety for patients, 7 and often delays or displaces needed care. 8 Overuse has many drivers, including health care system factors, the practice environment, the culture of professional medicine, and societal expectations for health care delivery. 3 While these external influences play an important role, patient–clinician interactions remain the nexus of decisions about inappropriate care. 3 It is, therefore, imperative for physicians to acquire the skills needed to promote value in clinical encounters. Promoting value in clinical encounters requires an understanding of the benefits, harms, and relative costs of a medical intervention, as well as the ability to apply this knowledge to individual patient interactions. 9 For example, physicians encounter patients requesting unnecessary diagnostic or therapeutic procedures 10,11 (e.g., a computed tomography [CT] scan for acute musculoskeletal low back pain, antibiotics for a viral illness). Conversations should focus on the premise that more medical care is not always better care. 9,12 However, many physicians find these “less-is- more” 9 conversations difficult, 13 and sophisticated communication skills are needed to respond to such requests in patient-centered and time-efficient ways. Medical education has a responsibility to address rising health care costs, 14 and equipping students with practical, patient-centered strategies to curb overuse is an important means by which to do this. To support educators in this endeavor, we developed a standardized patient (SP) scenario assessing medical students’ ability to respond to requests for unnecessary testing. Previously, we published validity evidence from a single institution supporting the use of the resulting scores for this purpose. 9 We found that scores from this “less-is- more” scenario did not correlate with faculty ratings of students’ interpersonal and communication skills on clerkships, suggesting that the skills required to promote value in clinical encounters are distinct from those needed for regular communication. The vast majority of participating students also reported that the scenario helped improve their high- value communication skills. 9 Based on these findings, we implemented the less-is-more scenario at 4 additional medical schools across the United States and undertook a multisite study both Abstract Purpose To examine validity evidence for a standardized patient scenario assessing medical students’ ability to promote value using patient-centered communication (in response to a patient requesting an unnecessary test) and to explore the potential effect of various implementation and curricular factors on student scores. Method Third-year medical students (N = 516) from 5 U.S. MD-granting medical schools completed the communication scenario between 2014 and 2017 as part of a larger objective structured clinical examination (OSCE). Centralized raters assessed performance using an 11-item checklist. The authors collected multiple sources of validity evidence. Results The mean checklist score was 0.85 (standard deviation 0.09). Interrater reliability for checklist scores was excellent (0.87, 95% confidence interval = 0.78–0.93). Generalizability and Phi-coefficients were, respectively, 0.65 and 0.57. Scores decreased as the number of OSCE stations increased (r = -0.15, P = .001) and increased when they were used for summative purposes (r = 0.26, P < .001). Scores were not associated with curricular time devoted to high-value care (r = 0.02, P = .67) and decreased when more clerkships were completed before the assessment (r = -0.12, P = .006). Conclusions This multisite study provides validity evidence supporting the use of scenario scores to assess the ability of medical students to promote value in clinical encounters using patient-centered communication. Findings illuminate the potential effect of OSCE structure and purpose on student performance and suggest clerkship learning experiences may not reinforce what students are taught in the formal curriculum regarding high-value care. Devoting more time to the topic appears insufficient to counteract this erosion. Promoting Value Through Patient-Centered Communication: A Multisite Validity Study of Third-Year Medical Students Neena Natt, MD, MMEd, Michael Dekhtyar, MEd, Yoon Soo Park, PhD, Kanade Shinkai, MD, PhD, Patricia A. Carney, PhD, MS, Tonya L. Fancher, MD, MPH, Luan Lawson, MD, and Andrea N. Leep Hunderfund, MD, MHPE Please see the end of this article for information about the authors. Correspondence should be addressed to Neena Natt, Mayo Clinic, Endocrinology, 200 First St. SW, Rochester, MN 55905; telephone: (507) 284-9576; email: natt.neena@mayo.edu. Copyright © 2020 by the Association of American Medical Colleges Acad Med. 2020;95:1900–1907. First published online May 26, 2020 doi: 10.1097/ACM.0000000000003519