Facing hierarchy: a qualitative study of residents' experiences in an obstetrical simulation scenario.

BACKGROUND: Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety. METHODS: Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30-45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached. RESULTS: Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging - a mere reporting of existing clinical information; (2) interpretive - a deliberate construction of clinical facts aimed at swaying supervising physician's clinical decision; and (3) advocative - a readiness to confront the staff physician's clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety. CONCLUSIONS: Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization.

Persistent complete hydatidiform molar pregnancy following assisted reproductive technology in a gestational carrier: Case report.

A hydatidiform mole is a rare pathology associated with pregnancy, attributed to abnormal gametogenesis and fertilization. When assisted reproduction techniques (ART) are used, the incidence of molar pregnancy is significantly lower however not eliminated. We report a case of a patient serving as a gestational carrier who developed a complete molar pregnancy, with features indicating persistent trophoblastic disease. This 33-year-old G4T3P0A1L3 woman presented with bleeding at 8 weeks gestational age, after in vitro fertilization and frozen embryo transfer. Ultrasound findings and beta-HCG levels were consistent with molar pregnancy. Pathology specimen from D&C confirmed a complete hydatidiform mole. Despite surgical treatment, beta-HCG remained elevated and multiple pulmonary nodules and enlarged lymph nodes were noted on imaging. Methotrexate was considered but was deemed unnecessary because beta-HCG levels returned to normal over time and nodules resolved. Because molar pregnancy carries a risk of malignant transformation, albeit low, individuals undergoing ART should be counselled.

Canadian Cardiovascular Society Cardiovascular Screening of Competitive Athletes: The Utility of the Screening Electrocardiogram to Predict Sudden Cardiac Death.

Prevention of sudden cardiac arrest/death (SCA/D) among athletes is a universal goal, although the optimal strategy for its achievement is controversial, with the inclusion of the 12-lead electrocardiogram (ECG) at the center of the debate. The ECG exhibits superior sensitivity over history and physical examination to detect conditions associated with SCA/D. However, the identification of disease does not necessarily lead to a significant reduction in SCA/D. The "Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes" recommended against the routine performance of an ECG for the initial cardiovascular screening of competitive athletes. The incidence of SCA/D among athletes (<35 years of age), the risk of SCA/D during sport participation among individuals with abnormalities found on screening ECG, the efficacy of the ECG to identify conditions associated with SCA/D, and the positive predictive value of an abnormal ECG to predict SCA/D are critically examined. This review presents the evidence informing the panel's recommendation.

Perseverance, faith and stoicism: a qualitative study of medical student perspectives on managing fatigue.

CONTEXT: Fatigue risk management (FRM) strategies offer a potential solution to the widespread problem of fatigued trainees in the clinical workplace. These strategies assume a shared perception that fatigue is hazardous. Despite the growing body of evidence suggesting that fatigue leads to burnout and medical errors, previous research suggests that residents perceive fatigue as a personal, surmountable burden rather than an occupational hazard. Before we can implement FRM, we need a better understanding of when and how such problematic notions of fatigue are adopted by medical trainees. Thus, we sought to explore how third-year medical students understand and manage the workplace fatigue they experience during their first year of clinical rotations. METHODS: A total of 22 third-year medical students participated in semi-structured interviews exploring their perspectives of workplace fatigue. Data collection and analysis occurred iteratively in keeping with constructivist grounded theory methodology and were informed by theoretical sampling to sufficiency. RESULTS: Our participants described unprecedented levels of sleep deprivation combined with uncertainty and confusion that led to significant fatigue during training. Drawing on their workplace experience, trainees believed that fatigue posed three distinct threats, which evoked different coping strategies: (i) threat to personal health, managed by perseverance; (ii) threat to patients, managed by faith in the system, and (iii) threat to professional reputation, managed by stoicism. CONCLUSIONS: Our findings highlight how senior medical students grapple with fatigue, as they understand it, within a training context in which they are expected to deny the impact of their fatigue on patients and themselves. Despite empirical evidence to the contrary, the prevailing assumption amongst our participants is that an ability to withstand sleep deprivation without impairment will develop naturally over time. Efforts to implement FRM strategies will need to address this assumption if these strategies are to be successfully taken up and effective.

Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes.

Sudden cardiac death (SCD), especially in a young seemingly healthy individual, is a tragic and highly publicized event, which is often followed by a strong emotional reaction from the public and medical community." Although rare, SCD in the young is devastating to families and communities, underpinning our society's desire to avoid any circumstances predisposing to the loss of human life during exertion. The Canadian Cardiovascular Society Position Statement on the cardiovascular screening of athletes provides evidence-based recommendations for Canadian sporting organizations and institutions with a focus on the role of routine electrocardiogram (ECG) screening in preventing SCD. We recommend that the cardiac screening and care of athletes within the Canadian health care model comprise a sequential (tiered) approach to the identification of cardiac risk, emphasizing the limitations of screening, the importance of shared decision-making when cardiac conditions are diagnosed, and the creation of policies and procedures for the management of emergencies in sport settings. Thus, we recommend against the routine (first-line or blanket mass performance of ECG) performance of a 12-lead ECG for the initial cardiovascular screening of competitive athletes. Organization/athlete-centred cardiovascular screening and care of athletes program is recommended. Such screening should occur in the context of a consistent, systematic approach to cardiovascular screening and care that provides: assessment, appropriate investigations, interpretation, management, counselling, and follow-up. The recommendations presented comprise a tiered framework that allows institutions some choice as to program creation.

Feasibility and Reliability of Nonexpert POCUS for Cardiovascular Preparticipation Screening of Varsity Athletes: The SHARP Protocol.

BACKGROUND: Point of care ultrasound (POCUS) is a potential adjunctive cardiovascular preparticipation screening modality for young competitive athletes. A novel cardiac POCUS screening protocol, Screening the Heart of the Athlete Research Program (SHARP), was developed for nonexpert examiners to assess common structural etiologies associated with sudden cardiac arrest/death (SCA/D). METHODS: Assessment of primary outcomes of feasibility, and reliability of obtained measurements, performed by comparison to formal transthoracic echocardiogram was undertaken. Inter-rater reliability was based on Intraclass correlation coefficients (ICC) defined as moderate for 0.40 to 0.59, good for 0.60 to 0.79, and excellent for 0.80 or greater. Electrocardiograms (ECGs) were also obtained. Identification of disease or other abnormalities was a secondary outcome. RESULTS: Fifty varsity athletes at our institution underwent the SHARP protocol, with 19 undergoing formal transthoracic echocardiogram and ECG for comparison. POCUS image quality was good to excellent. Feasibility of assessing for hypertrophic cardiomyopathy, aortic root dilatation, and left-ventricular function was deemed highly possible but limited in 20% for right-ventricular assessment. Reliability was good for measurements of interventricular septal thickness (0.67), end diastolic left-ventricular diameter (0.61), aortic root diameter (0.63), and moderate for left-ventricular posterior wall thickness (0.42). No cardiovascular abnormalities were detected. CONCLUSIONS: A novel, comprehensive SHARP POCUS protocol performed by nonexpert practitioners demonstrated feasibility and reliability to assess varsity level athletes for common structural etiologies associated with SCA/D. Further large athlete screening cohort studies are required to validate the SHARP protocol and the role of cardiac POCUS as a screening modality.

Variation in Preparticipation Screening Medical Questionnaires and Physical Examinations Across Canadian Universities.

Pre-participation screening of athletes to prevent sudden cardiac arrest or death is endorsed by international guidelines. Standardized histories and physical examinations are recommended to optimize effectiveness. To assess current screening practices across Canada in the university athlete population, we sought to analyze the preparticipation screening form of all universities. A comparative analysis to recommendations from the American Heart Association (AHA), European Society of Cardiology (ESC), and the Preparticipation Physical Evaluation (PPE-4) was conducted. Pre-participation forms from 30 of 56 U Sports universities were obtained. Adherence to published guidelines was highly variable. Ten percent strictly followed any of the 3 guideline recommendations, and only 43% contained at least 75% of the recommended items. Average percentage adherence to AHA and ESC guidelines was statistically significantly higher than adherence to the PPE-4 (62.2% and 66.1%, respectively, vs 52.7%, P < 0.001). Family history of common cardiac conditions predisposing athletes to sudden cardiac death and family history of sudden or unexpected death was omitted in 80% and 30% of forms, respectively. Recommendations for examining for stigmata of Marfan syndrome and assessment of femoral pulses was absent on more than 70% of forms. Although there is great controversy regarding the benefits and impact of screening, our results suggest that Canadian universities are conducting pre-participation screening although in a highly variable manner. Incomplete and variable screening questionnaires employed by Canadian universities may negatively affect the potential to identify athletes with underlying disease. We recommend that, if pre-participation screening is performed, a guideline-based questionnaire be used to optimize accuracy.

Current Practices and Attitudes of Canadian Team Physicians Toward Cardiovascular Preparticipation Screening.

To determine the current cardiovascular preparticipation screening practices and attitudes of team physicians for Canadian University and Major Junior Hockey Athletes, a 13-question survey was distributed to lead physicians of each organization. The response rate was 47% (48% [27 of 56] for the Canadian Interuniversity Sport and 55% [11 of 20] for the Ontario Hockey League). Ninety-two percent of physicians reported some form of preparticipation screening, with 22% currently using 12-lead electrocardiogram. Substantial inter- and intraorganization variability existed. Physicians not performing electrocardiogram screening reported lack of evidence (45%) and lack of cost-effectiveness (28%) as their rationale. To our knowledge, this is the first study to investigate Canadian athletic screening practices, and highlights the need for national guidelines.