1
|
Kanjee Z, Beltran CP, Smith CC, Tibbles CD, Lewis JJ, Sullivan AM. "Two Years Later I'm Still Just as Angry": A Focus Group Study of Emergency and Internal Medicine Physicians on Disrespectful Communication. Teach Learn Med 2023:1-11. [PMID: 38041804 DOI: 10.1080/10401334.2023.2288706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/07/2023] [Indexed: 12/04/2023]
Abstract
Phenomenon: Disrespectful behavior between physicians across departments can contribute to burnout, poor learning environments, and adverse patient outcomes. Approach: In this focus group study, we aimed to describe the nature and context of perceived disrespectful communication between emergency and internal medicine physicians (residents and faculty) at patient handoff. We used a constructivist approach and framework method of content analysis to conduct and analyze focus group data from 24 residents and 11 faculty members from May to December 2019 at a large academic medical center. Findings: We organized focus group results into four overarching categories related to disrespectful communication: characteristics and context (including specific phrasing that members from each department interpreted as disrespectful, effects of listener engagement/disengagement, and the tendency for communication that is not in-person to result in misunderstanding and conflict); differences across training levels (with disrespectful communication more likely when participants were at different training levels); the individual correspondent's tendency toward perceived rudeness; and negative/long-term impacts of disrespectful communication on the individual and environment (including avoidance and effects on patient care). Insights: In the context of predominantly positive descriptions of interdepartmental communication, participants described episodes of perceived disrespectful behavior that often had long-lasting, negative impacts on the quality of the learning environment and clinical work. We created a conceptual model illustrating the process and outcomes of these interactions. We make several recommendations to reduce disrespectful communication that can be applied throughout the hospital to potentially improve patient care, interdepartmental collaboration, and trainee and faculty quality of life.
Collapse
Affiliation(s)
- Zahir Kanjee
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine P Beltran
- Program for Medical Education Innovations and Research, New York University Grossman School of Medicine, New York, New York, USA
| | - C Christopher Smith
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Carrie D Tibbles
- Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jason J Lewis
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amy M Sullivan
- Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Ricotta DN, Richards JB, Atkins KM, Hayes MM, McOwen K, Soffler MI, Tibbles CD, Whelan AJ, Schwartzstein RM. Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery. Teach Learn Med 2022; 34:530-540. [PMID: 34279167 DOI: 10.1080/10401334.2021.1938074] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .
Collapse
Affiliation(s)
- Daniel N Ricotta
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy B Richards
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - K Meredith Atkins
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret M Hayes
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine McOwen
- Association of American Medical Colleges, Washington, District of Columbia, USA
| | - Morgan I Soffler
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Carrie D Tibbles
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alison J Whelan
- Association of American Medical Colleges, Washington, District of Columbia, USA
| | - Richard M Schwartzstein
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Sullivan AM, Beltran CP, Ranchoff BL, Hayes MM, Atkins KM, Tibbles CD, Cohen AP, Cohen DA, Huang GC, Schwartzstein RM. Enhancing Clinical Teaching in Critical Thinking, High-Value Care, and Health Care Equity. J Contin Educ Health Prof 2022; 42:164-173. [PMID: 36007516 DOI: 10.1097/ceh.0000000000000441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE). METHODS The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution. RESULTS Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). Sixty-eight (IG n = 28, CG n = 23, WG n = 17) were observed, with a median of 3 observation sessions and 5.2 hours each. Postintervention comparison of teaching (average counts/hour) showed statistically significant differences across groups: CT CG = 4.1, IG = 4.8, WG = 8.2; HVC CG = 0.6, IG = 0.9, WG = 1.6; and HCE CG = 0.2, IG = 0.4, WG = 1.4 ( P < .001). DISCUSSION A faculty development intervention focused on teaching in the context of providing clinical care resulted in more frequent teaching of CT, HVC, and HCE in the intervention group compared with controls. WG faculty demonstrated highest teaching counts and provide benchmarks to assess future interventions. With the creation of durable teaching materials and a cadre of trained faculty, this project sets a foundation for infusing substantive content into clinical teaching.
Collapse
Affiliation(s)
- Amy M Sullivan
- Sullivan: Associate Professor, Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. Beltran: Research Manager, Beth Israel Deaconess Medical Center, Boston, MA. Ranchoff: PhD Candidate, University of Massachusetts, Amherst, MA. Dr. Hayes: Assistant Professor, Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. Dr. Atkins: Assistant Professor, Department of Obstetrics and Gynecology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. Dr. Huang: Associate Professor, Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. Dr. Tibbles: Assistant Professor, Department of Emergency Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA. Cohen: Instructor, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA. Dr. Cohen: Assistant Professor, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. Dr. Schwartzstein: Professor of Medicine, Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Wu A, Parris RS, Scarella TM, Tibbles CD, Torous J, Hill KP. What gets resident physicians stressed and how would they prefer to be supported? A best-worst scaling study. Postgrad Med J 2021; 98:930-935. [PMID: 34810273 DOI: 10.1136/postgradmedj-2021-140719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Physician burnout has severe consequences on clinician well-being. Residents face numerous work-stressors that can contribute to burnout; however, given specialty variation in work-stress, it is difficult to identify systemic stressors and implement effective burnout interventions on an institutional level. Assessing resident preferences by specialty for common wellness interventions could also contribute to improved efficacy. METHODS This cross-sectional study used best-worst scaling (BWS), a type of discrete choice modelling, to explore how 267 residents across nine specialties (anaesthesiology, emergency medicine, internal medicine, neurology, obstetrics and gynaecology, pathology, psychiatry, radiology and surgery) prioritised 16 work-stressors and 4 wellness interventions at a large academic medical centre during the COVID-19 pandemic (December 2020). RESULTS Top-ranked stressors were work-life integration and electronic health record documentation. Therapy (63%, selected as 'would realistically consider intervention') and coaching (58%) were the most preferred wellness supports in comparison to group-based peer support (20%) and individual peer support (22%). Pathology, psychiatry and OBGYN specialties were most willing to consider all intervention options, with emergency medicine and internal medicine specialties least willing to consider intervention options. CONCLUSION BWS can identify relative differences in surveyed stressors, allowing for the generation of specialty-specific stressor rankings and preferences for specific wellness interventions that can be used to drive institution-wide changes to improve clinician wellness. BWS surveys are a potential methodology for clinician wellness programmes to gather specific information on preferences to determine best practices for resident wellness.
Collapse
Affiliation(s)
- Andrew Wu
- Psychiatry, Harvard Medical School, Boston, Massachusetts, USA .,Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ritika S Parris
- Office of Graduate Medical Education, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy M Scarella
- Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Carrie D Tibbles
- Office of Graduate Medical Education, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - John Torous
- Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin P Hill
- Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Stippler M, Keith S, Nelton EB, Parsons CS, Singleton J, Bilello LA, Tibbles CD, Davis RB, Edlow JA, Rosen CL. Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa504_s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
6
|
Kanjee Z, Beltran CP, Smith CC, Lewis J, Hall MM, Tibbles CD, Sullivan AM. "Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center. West J Emerg Med 2021; 22:1227-1239. [PMID: 34787545 PMCID: PMC8597691 DOI: 10.5811/westjem.2021.7.52762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. METHODS We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. RESULTS From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). CONCLUSIONS Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.
Collapse
Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Christine P Beltran
- Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
| | - C Christopher Smith
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Internal Medicine Residency Program, Boston, Massachusetts
| | - Jason Lewis
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Matthew M Hall
- Providence Regional Medical Center, Department of Emergency Medicine, Everett, Washington.,Washington State University, Pullman, Washington
| | - Carrie D Tibbles
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Emergency Medicine Residency Program, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Office of Graduate Medical Education, Boston, Massachusetts
| | - Amy M Sullivan
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
| |
Collapse
|
7
|
Stippler M, Keith S, Nelton EB, Parsons CS, Singleton J, Bilello LA, Tibbles CD, Davis RB, Edlow JA, Rosen CL. Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes. Neurosurgery 2021; 88:773-778. [PMID: 33469647 PMCID: PMC7956047 DOI: 10.1093/neuros/nyaa504] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/21/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population. OBJECTIVE To report our experience with protocol implications and patient outcome. METHODS Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed. RESULTS Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations. CONCLUSION Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.
Collapse
Affiliation(s)
- Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stacey Keith
- Division of Acute Care, Trauma, and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Emmalin B Nelton
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Charles S Parsons
- Division of Acute Care, Trauma, and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Singleton
- Department of Emergency Medicine, UC Health Highlands Ranch Hospital, University of Colorado School of Medicine, Aurora, Colorado
| | - Leslie A Bilello
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carrie D Tibbles
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger B Davis
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
8
|
Gurley KL, Grossman SA, Janes M, Yu‐Moe CW, Song E, Tibbles CD, Shapiro NI, Rosen CL. Comparison of Emergency Medicine Malpractice Cases Involving Residents to Nonresident Cases. Acad Emerg Med 2018; 25:980-986. [PMID: 29665190 DOI: 10.1111/acem.13430] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Data are lacking on how emergency medicine (EM) malpractice cases with resident involvement differs from cases that do not name a resident. OBJECTIVES The objective was to compare malpractice case characteristics in cases where a resident is involved (resident case) to cases that do not involve a resident (nonresident case) and to determine factors that contribute to malpractice cases utilizing EM as a model for malpractice claims across other medical specialties. METHODS We used data from the Controlled Risk Insurance Company (CRICO) Strategies' division Comparative Benchmarking System (CBS) to analyze open and closed EM cases asserted from 2009 to 2013. The CBS database is a national repository that contains professional liability data on > 400 hospitals and > 165,000 physicians, representing over 30% of all malpractice cases in the United States (>350,000 claims). We compared cases naming residents (either alone or in combination with an attending) to those that did not involve a resident (nonresident cohort). We reported the case statistics, allegation categories, severity scores, procedural data, final diagnoses, and contributing factors. Fisher's exact test or t-test was used for comparisons (alpha set at 0.05). RESULTS A total of 845 EM cases were identified of which 732 (87%) did not name a resident (nonresident cases), while 113 (13%) included a resident (resident cases). There were higher total incurred losses for nonresident cases. The most frequent allegation categories in both cohorts were "failure or delay in diagnosis/misdiagnosis" and "medical treatment" (nonsurgical procedures or treatment regimens, i.e., central line placement). Allegation categories of safety and security, patient monitoring, hospital policy and procedure, and breach of confidentiality were found in the nonresident cases. Resident cases incurred lower payments on average ($51,163 vs. $156,212 per case). Sixty-six percent (75) of resident versus 57% (415) of nonresident cases were high-severity claims (permanent, grave disability or death; p = 0.05). Procedures involved were identified in 32% (36) of resident and 26% (188) of nonresident cases (p = 0.17). The final diagnoses in resident cases were more often cardiac related (19% [21] vs. 10% [71], p < 0.005) whereas nonresident cases had more orthopedic-related final diagnoses (10% [72] vs. 3% [3], p < 0.01). The most common contributing factors in resident and nonresident cases were clinical judgment (71% vs. 76% [p = 0.24]), communication (27% vs. 30% [p = 0.46]), and documentation (20% vs. 21% [p = 0.95]). Technical skills contributed to 20% (22) of resident cases versus 13% (96) of nonresident cases (p = 0.07) but those procedures involving vascular access (2.7% [3] vs 0.1% [1]) and spinal procedures (3.5% [4] vs. 1.1% [8]) were more prevalent in resident cases (p < 0.05 for each). CONCLUSIONS There are higher total incurred losses in nonresident cases. There are higher severity scores in resident cases. The overall case profiles, including allegation categories, final diagnoses, and contributing factors between resident and nonresident cases are similar. Cases involving residents are more likely to involve certain technical skills, specifically vascular access and spinal procedures, which may have important implications regarding supervision. Clinical judgment, communication, and documentation are the most prevalent contributing factors in all cases and should be targets for risk reduction strategies.
Collapse
Affiliation(s)
- Kiersten L. Gurley
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
- Mount Auburn Hospital Cambridge MA
| | - Shamai A. Grossman
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | | | | | - Ellen Song
- CRICO/Risk Management Foundation Boston MA
| | - Carrie D. Tibbles
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | - Carlo L. Rosen
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| |
Collapse
|
9
|
Abstract
ISSUE Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. EVIDENCE Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. IMPLICATIONS Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.
Collapse
Affiliation(s)
- Grace C Huang
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Carrie D Tibbles
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Lori R Newman
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Richard M Schwartzstein
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| |
Collapse
|
10
|
Dubosh NM, Carney D, Fisher J, Tibbles CD. Implementation of an emergency department sign-out checklist improves transfer of information at shift change. J Emerg Med 2014; 47:580-5. [PMID: 25130675 DOI: 10.1016/j.jemermed.2014.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 04/25/2014] [Accepted: 06/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Transitions of care are ubiquitous in the emergency department (ED) and inevitably introduce the opportunity for errors. Few emergency medicine residency programs provide formal training or a standard process for patient handoffs. Checklists have been shown to be effective quality-improvement measures in inpatient settings and may be a feasible method to improve ED handoffs. OBJECTIVE To determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ED. METHODS A prospective pre-/postinterventional study of residents rotating in the ED at a tertiary academic medical center. Trained research assistants observed resident sign-out during shift change over a 2-week period and completed a data collection tool to indicate whether or not key components of sign-out occurred and time to sign out each patient. An electronic sign-out checklist was implemented using a multi-faceted educational effort. A 2-week postintervention observation phase was conducted. Proportions, means, and nonparametric comparison tests were calculated using STATA. RESULTS One hundred fifteen sign-outs were observed prior to checklist implementation and 114 were observed after. Significant improvements were seen in four sign-out components: reporting of history of present illness increased from 81% to 99%, ED course increased from 75% to 86%, likely diagnosis increased from 60% to 77%, and team awareness of plan increased from 21% to 41%. Use of the repeat-back technique decreased from 13% to 5% after checklist implementation and time to sign-out showed no significant change. CONCLUSION Implementation of a checklist improved the transfer of information without increasing time to sign-out.
Collapse
Affiliation(s)
- Nicole M Dubosh
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Dylan Carney
- Department of Emergency Medicine, University of California at San Francisco, San Francisco, CA
| | - Jonathan Fisher
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carrie D Tibbles
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
11
|
Bivens MJ, Boegle AK, Jesus JE, Camacho MA, Tibbles CD, Madsen BE. Headache, hand clumsiness, and "involuntary serial sevens" in a young person. J Emerg Med 2014; 47:71-75. [PMID: 24816180 DOI: 10.1016/j.jemermed.2012.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 12/18/2012] [Indexed: 06/03/2023]
MESH Headings
- Adult
- Anticoagulants/therapeutic use
- Aphasia/etiology
- Ataxia/etiology
- Carotid Artery Thrombosis/complications
- Carotid Artery Thrombosis/diagnostic imaging
- Carotid Artery Thrombosis/drug therapy
- Carotid Artery, Internal
- Carotid Artery, Internal, Dissection/complications
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Carotid Artery, Internal, Dissection/drug therapy
- Chronic Disease
- Female
- Hand
- Headache/etiology
- Heparin/therapeutic use
- Humans
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/drug therapy
- Infarction, Middle Cerebral Artery/etiology
- Neurologic Examination
- Radiography
- Vasoconstrictor Agents/therapeutic use
- Vertebral Artery Dissection/complications
- Vertebral Artery Dissection/diagnostic imaging
- Vertebral Artery Dissection/drug therapy
Collapse
Affiliation(s)
- Matthew J Bivens
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aimee K Boegle
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John E Jesus
- Department of Emergency Medicine, Christiana Hospital, Delaware
| | - Marc A Camacho
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carrie D Tibbles
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bo E Madsen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
12
|
Horng S, Pezzella L, Tibbles CD, Wolfe RE, Hurst JM, Nathanson LA. Prospective Evaluation of Daily Performance Metrics to Reduce Emergency Department Length of Stay for Surgical Consults. J Emerg Med 2013; 44:519-25. [DOI: 10.1016/j.jemermed.2012.02.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 01/04/2012] [Accepted: 02/28/2012] [Indexed: 10/28/2022]
|
13
|
Kroll KE, Kroll DS, Pope JV, Tibbles CD. Catatonia in the emergency department. J Emerg Med 2012; 43:843-846. [PMID: 22541876 DOI: 10.1016/j.jemermed.2012.02.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 02/11/2012] [Indexed: 05/31/2023]
Affiliation(s)
- Katherine E Kroll
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
| | | | | | | |
Collapse
|
14
|
Affiliation(s)
- Eugene S Yim
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | |
Collapse
|
15
|
Betz ME, Bernstein SL, Gutman DC, Tibbles CD, Joyce NR, Lipton RI, Schweigler LM, Fisher J. Public health education for emergency medicine residents. Am J Prev Med 2011; 41:S242-50. [PMID: 21961671 PMCID: PMC4531839 DOI: 10.1016/j.amepre.2011.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 06/02/2011] [Accepted: 06/05/2011] [Indexed: 11/29/2022]
Abstract
Emergency medicine (EM) has an important role in public health, but the ideal approach for teaching public health to EM residents is unclear. As part of the national Regional Public Health-Medicine Education Centers-Graduate Medical Education initiative from the CDC and the American Association of Medical Colleges, three EM programs received funding to create public health curricula for EM residents. Curricula approaches varied by residency. One program used a modular, integrative approach to combine public health and EM clinical topics during usual residency didactics, one partnered with local public health organizations to provide real-world experiences for residents, and one drew on existing national as well as departmental resources to seamlessly integrate more public health-oriented educational activities within the existing residency curriculum. The modular and integrative approaches appeared to have a positive impact on resident attitudes toward public health, and a majority of EM residents at that program believed public health training is important. Reliance on pre-existing community partnerships facilitated development of public health rotations for residents. External funding for these efforts was critical to their success, given the time and financial restraints on residency programs. The optimal approach for public health education for EM residents has not been defined.
Collapse
Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
The care of the pregnant trauma patient provides unique challenges and holds profound implications for both fetal and maternal outcomes. The management of these patients is influenced by unique anatomic and physiologic changes, increased concern for deleterious radiation and medication exposures, and the need for multidisciplinary care. This article reviews the critical features necessary in the assessment, diagnosis, treatment, and disposition of pregnant trauma patients with a focus on recent developments reported in the literature as pertinent to emergency management.
Collapse
Affiliation(s)
- Seric S Cusick
- Department of Emergency Medicine, UC Davis School of Medicine, PSSB, 4150 V Street, #2100, Sacramento, CA 95817, USA
| | | |
Collapse
|
17
|
|
18
|
Abstract
CONTEXT Erythema migrans, while not pathognomonic, is the most common manifestation of early Lyme disease. Accurate diagnosis of this rash is essential to initiating appropriate antibiotic therapy. OBJECTIVE To determine the sensitivity of history and physical examination characteristics for the diagnosis of erythema migrans. DATA SOURCES Structured MEDLINE searches of articles written only in English, 1966 through March 2007. STUDY SELECTION Studies were included if they enrolled at least 15 consecutive patients with the diagnosis of erythema migrans and reported original data regarding the history and physical examination characteristics of the patients. DATA EXTRACTION One author abstracted data from the studies. RESULTS We separately analyzed the studies from Europe and analyzed both Lyme-endemic and nonendemic areas of the United States to search for potential differences in the clinical presentation. Thirty-two studies from Europe, 20 studies from the United States, and 1 from Europe and the United States met inclusion criteria for a total of 8493 patients. Sensitivity was calculated for each of the variables. No studies included patients without erythema migrans, so specificity data and likelihood ratios could not be determined. Many patients do not recall a tick bite. Associated systemic symptoms, such as fever and headache, are frequently reported. Nausea and vomiting are rare. A solitary lesion is the most frequent presentation in both US (81%; 95% confidence interval [CI], 72%-87%) and European patients (88%; 95% CI, 81%-93%). Central clearing is less common in the endemic United States (19%; 95% CI, 11%-32%) vs Europe (79%; 95% CI, 69%-86%) and the nonendemic United States (80%; 95% CI, 63%-90%). CONCLUSIONS Our analysis of the current available literature suggests that there is no single element in the history or physical examination that is highly sensitive by itself for the diagnosis of erythema migrans. Clinicians should be aware of the wide variability in the clinical presentation of erythema migrans and the need to factor in multiple components of the clinical examination and epidemiological context.
Collapse
Affiliation(s)
- Carrie D Tibbles
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Harvard Medical School, West Clinical Center 2, One Deaconess Road, Boston, MA 02215, USA.
| | | |
Collapse
|
19
|
Abstract
Many invasive procedures are now safer and more efficient with the use of ultrasound guidance. As emergency physicians continue to develop skills in sonography, new applications of this technology will continue to impact the practice of emergency medicine.
Collapse
Affiliation(s)
- Carrie D Tibbles
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, West Campus Clinical Center 2, One Deaconess Road, Boston, MA 02215, USA.
| | | |
Collapse
|
20
|
Smith SW, Tibbles CD, Apple FS, Zimmerman M. Outcome of low-risk patients discharged home after a normal cardiac troponin I. J Emerg Med 2004; 26:401-6. [PMID: 15093844 DOI: 10.1016/j.jemermed.2003.12.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2003] [Revised: 11/25/2003] [Accepted: 12/08/2003] [Indexed: 11/17/2022]
Abstract
Patients with symptoms suggestive of, but at low risk for, acute coronary syndrome (ACS), who have a negative electrocardiogram (EKG) and a single normal troponin I at 6-9 h after symptom onset are frequently discharged from our Emergency Department (ED). We sought to determine their rate of adverse cardiac events at 30 days (ACE-30), defined as cardiac death or myocardial infarction (MI), by chart review, telephone interview, or county death records. Of 663 patients, data were available for 588 (89%). Mean age was 48 years; 59% were male. There were 390 patients (66%) who complained of chest pain. Previous coronary artery disease (CAD) was reported in 145 patients (25%). Two patients (0.34%) had ACE-30, both with non-ST elevation MI. There were no cases of cardiac death. None of the patients died in Hennepin County within 30 days. At our institution, low-risk patients with symptoms suggestive of ACS who are discharged home after a normal cTnI drawn 6-9 h after symptom onset have a very low incidence of cardiac events at 30 days.
Collapse
Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA
| | | | | | | |
Collapse
|
21
|
Abstract
OBJECTIVES The prevalence and necessity for early detection of vision problems illustrate the need for improved methods of vision screening in preschool children. This study assessed the validity and reliability of a new device, the MTI photoscreener in a cross-sectional field study. METHODS An appropriate sample size (> 140) was calculated and recruited for the study. All children (N = 161) in a migrant workers summer education program were screened with the MTI Photoscreener. Simultaneously and in a masked design, disease status was determined by the Modified Clinic Technique, a well established method for diagnosing the conditions which the MTI screener was designed to detect. RESULTS Validity measures revealed a sensitivity of 54%, specificity of 87%, phi coefficient of 0.40, and positive predictive value of 52%. Repeatability was assessed by the kappa coefficient, by a test for effect modification by examiner, and by comparison of sensitivity and specificity across 12 masked examiners. The kappa coefficient was 0.38. A test for effect modification suggested that differences existed among the examiners. Variability of sensitivity was high, but variability of specificity was low. CONCLUSIONS Methods for vision screening in preschool children are limited. The MTI Photoscreener is an easy and efficient method, but the validity and reliability is a concern. Comparison of our results with other studies suggests future potential for this instrument provided protocols are refined and further field studies reveal efficacy.
Collapse
Affiliation(s)
- S Hatch
- New England College of Optometry, Boston, Massachusetts, USA
| | | | | | | | | | | |
Collapse
|