Medicine's Shame Problem.

BACKGROUND: Physician mental health is an increasingly discussed topic. Despite the progress made regarding the discussion of physician mental health, these issues remain concerning. In particular, the discussion as to why these issues are so problematic remains limited. Contributors can include bullying, the "hidden curriculum" of medicine, how the medical culture handles errors, and importantly, shame. OBJECTIVE: This narrative review evaluates the literature on bullying and abuse in medicine, how abuse can exacerbate shame, how the handling of medical errors can exacerbate shame, how shame can negatively affect mental health, and how the medical community and leaders can mitigate these issues. DISCUSSION: Physician mental health remains an important issue. Job-related stressors, bullying, medicine's hidden curriculum, medical error, traumatic patient encounters, and perfectionism can contribute to physician depression and burnout. Shame may underlie these factors. Shame is a universal emotion that leads to poor self-esteem, depression, eating disorders, abuse, and addiction. However, shame can be addressed and overcome, especially via acknowledgment, vulnerability, and empathy. The medical community can provide some of these techniques by encouraging environments of kindness and respect, giving constructive rather than destructive feedback, providing empathy and support after a medical error, and encouraging mutual learning environments where questions are asked with respect in order to enhance learning. This is opposed to hierarchies and "pimping," where questions are asked with intimidation and disrespect. CONCLUSIONS: Shame is likely a contributor to physician mental health issues. For shame resilience to occur, it must not be kept secret and mutual support should be provided. By addressing the possible causes behind physician mental health concerns, including shame, more solutions can be proposed.

Task dependence of odor discrimination: choosing between speed and accuracy.

Odor discrimination is a complex task that may be improved by increasing sampling time to facilitate evidence accumulation. However, experiments testing this phenomenon in olfaction have produced conflicting results. To resolve this disparity, Frederick et al. (Frederick DE, Brown A, Tacopina S, Mehta N, Vujovic M, Brim E, Amina T, Fixsen B, Kay LM. J Neurosci 37: 4416-4426, 2017) conducted experiments that suggest that sampling time and performance are task dependent. Their findings have implications for understanding olfactory processing and experimental design, specifically the effect of subtle differences in experimental design on study results.

Suffering in Silence: Medical Error and its Impact on Health Care Providers.

BACKGROUND: All humans are fallible. Because physicians are human, unintentional errors unfortunately occur. While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality. OBJECTIVES: The objectives of this article are to 1) discuss the impact medical error has on involved provider(s), 2) provide potential reasons why medical error can have a negative impact on provider mental health, and 3) suggest solutions for providers and health care organizations to recognize and mitigate the adverse effects medical error has on providers. DISCUSSION: Physicians and other providers may feel a variety of adverse emotions after medical error, including guilt, shame, anxiety, fear, and depression. It is thought that the pervasive culture of perfectionism and individual blame in medicine plays a considerable role toward these negative effects. In addition, studies have found that despite physicians' desire for support after medical error, many physicians feel a lack of personal and administrative support. This may further contribute to poor emotional well-being. Potential solutions in the literature are proposed, including provider counseling, learning from mistakes without fear of punishment, discussing mistakes with others, focusing on the system versus the individual, and emphasizing provider wellness. Much of the reviewed literature is limited in terms of an emergency medicine focus or even regarding physicians in general. In addition, most studies are survey- or interview-based, which limits objectivity. While additional, more objective research is needed in terms of mitigating the effects of error on physicians, this review may help provide insight and support for those who feel alone in their attempt to heal after being involved in an adverse medical event. CONCLUSIONS: Unintentional medical error will likely always be a part of the medical system. However, by focusing on provider as well as patient health, we may be able to foster resilience in providers and improve care for patients in healthy, safe, and constructive environments.

Emergency Medicine Myths: Ectopic Pregnancy Evaluation, Risk Factors, and Presentation.

BACKGROUND: Ectopic pregnancy (EP) is an important cause of morbidity and mortality in females of reproductive age. Proper diagnosis and treatment are critical, as complications such as rupture, hemorrhagic shock, and even death can occur. OBJECTIVE: EP is a condition emergency physicians are trained to detect, yet there are multiple myths concerning its evaluation and diagnosis. This article reviews several of these myths in order to improve emergency department (ED) evaluation and diagnosis. DISCUSSION: EP is a difficult diagnosis and may be missed on initial ED visit. While the diagnosis is often delayed simply due to very early presentations, it can also be missed because patients may not have all the same risk factors or demonstrate the same symptoms. They may also not demonstrate the same serum B-human chorionic gonadotropin levels and trends or have the same ultrasound findings at equivalent gestational ages. Some patients with early EP may have positive ultrasound findings with serum ß-hCG levels under a defined discriminatory zone (DZ). On the other hand, some patients with an early viable intrauterine pregnancy may have no visible findings on initial ultrasound, but have serum ß-hCG (quantitative) levels well above the DZ. Although rare, EP has even been demonstrated in women with negative urine ß-hCG tests or low serum ß-hCG levels. CONCLUSIONS: While EP may be a challenging diagnosis, understanding the myths surrounding EP may help emergency physicians consider it, even when patient risk factors, symptoms, or ED laboratory or imaging studies do not initially or easily define the diagnosis.

The Acute Hemolytic Anemias: The Importance of Emergency Diagnosis and Management.

BACKGROUND: Hemolytic anemias are defined by the premature destruction of red blood cells. These anemias have many causes that are mostly due to chronic diseases, but, occasionally, cases of acute life-threatening hemolysis can occur. OBJECTIVE: The objectives of this article were to review the pathophysiology of hemolytic anemias, to discuss the general emergency department (ED) evaluation, and to discuss the assessment and treatment of important and "cannot miss" hemolytic diseases. DISCUSSION: Because hemolytic anemias are rarely seen, the emergency physician may consider a patient's anemia as due to blood loss rather than hemolysis, and the workup and treatment may not be appropriate. The primary goal for the emergency provider is to resuscitate, but he or she also must recognize that a hemolytic process is present. Appropriate laboratory work and specialist consultation should be obtained. While focused treatment is rarely necessary in the ED, the avoidance of certain treatments, such as early platelet transfusion in thrombotic thrombocytopenic purpura, may be necessary. CONCLUSIONS: Hemolytic anemias are rare, but should still be considered in the ED differential diagnosis of low hemoglobin. Emergency physicians should first resuscitate, but should also be able to identify the presence of hemolysis and obtain the appropriate laboratory tests. Occasionally, specific treatments are needed but should be discussed in conjunction with a specialist.

Myths in the Evaluation and Management of Ovarian Torsion.

BACKGROUND: Ovarian torsion is a rare but serious cause of pelvic pain in females. Making the diagnosis is important because misdiagnosis can lead to an ischemic ovary and subsequent infertility. OBJECTIVE: Although all emergency physicians are aware of ovarian torsion, there are several myths regarding its epidemiology, diagnosis, and treatment. This article attempts to review some of these myths to improve emergency diagnosis and evaluation. DISCUSSION: Ovarian torsion is not an easy diagnosis to make and it is commonly missed. Signs and symptoms often mimic other disorders such as appendicitis, pyelonephritis, and nephrolithiasis. The diagnosis becomes more challenging in that torsion can occur in female patients of all ages, including infants and the elderly. Normal arterial blood flow on ultrasound does not rule out ovarian torsion and not every patient will have a mass on imaging or a palpable mass on examination. Patients may have symptoms for several hours or days, and thus, ovarian torsion may be present even with a longer duration of symptoms. Surgery is the definitive treatment and may still be effective after several hours of symptoms. CONCLUSIONS: Although ovarian torsion is a challenging diagnosis, understanding myths surrounding the disorder may help emergency physicians consider it in unusual populations. If there is any clinical concern for ovarian torsion, a gynecologic consult may be helpful, even if imaging findings are not conclusive. Surgery remains the standard method for definitive diagnosis and treatment.

Cervical Artery Dissections: A Review.

BACKGROUND: Cervical artery dissection (CeAD) is an infrequent, yet potentially devastating, cause of stroke. While uncommon, CeAD is important for emergency physicians to quickly diagnose and treat because of the potential for cerebral ischemia, stroke, blindness, or death. To our knowledge, no review articles in the emergency medicine literature have been published on CeAD. A literature search of MEDLINE/PubMed, Embase, and other major abstracts in the English language was performed for the following terms: cervical artery, vertebral artery, and carotid artery dissection. The search included all titles from January 1, 2010 to February 28, 2015 and other relevant articles. OBJECTIVES: We sought to review the epidemiology, pathophysiology, risk factors, and clinical presentation for extracranial CeAD in the adult population, explore recent research on diagnosing this disorder, evaluate the most current research on treatment options, and summarize the prognosis of CeAD. DISCUSSION: CeAD is an uncommon but important cause of stroke in the young that is likely caused by multifactorial processes. The diagnosis should be considered in those with underlying risk factors, a remote history of minor trauma, and concerning signs and symptoms. The condition should be pursued via magnetic resonance imaging or computed tomography angiography. Treatment should be aimed at preventing additional complications, including recurrent stroke or transient ischemic attack, with antiplatelets, anticoagulants, or even endovascular or surgical therapy. CONCLUSION: Overall, the prognosis of patients with CeAD is good, with relatively low death rates. However, the diagnosis should not be missed, because treatment may help prevent worsening or persistent ischemia, recurrent dissection, and death.

An Unusual Cause of Chest Pain in a Young Healthy Female.

BACKGROUND: Infection of the sternoclavicular joint is an uncommon disease that is usually seen in patients with underlying risk factors such as prior trauma, intravenous drug use, or diabetes mellitus. The true pathophysiology remains unknown, but underlying bacteremia has been found in a number of cases. Without proper diagnosis and treatment, severe complications such as mediastinitis, sepsis, or death can occur. CASE REPORT: This is a case of spontaneous stenoclavicular septic arthritis in an otherwise healthy female. The patient's lack of risk factors and minimal examination findings highlight the unusual nature of the case, as well as the challenges it presents in making an early diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS CONDITION?: Emergency physicians should consider sternoclavicular joint infections in patients who present to the emergency department with chest pain, even in patients without risk factors. They should especially consider the diagnosis in patients with suspected musculoskeletal etiologies or in those with return visits for chest pain. Although most patients do well with treatment, the infection can be life threatening without appropriate interventions.

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

OBJECTIVE: To investigate the use of a trigger tool for the detection of adverse drug events (ADE) in a pediatric hospital specializing in oncology, hematology, and other catastrophic diseases. STUDY DESIGN: A medication-based trigger tool package analyzed electronic health records from February 2009 to February 2013. Chart review determined whether an ADE precipitated the trigger. Severity was assigned to ADEs, and preventability was assessed. Preventable ADEs were compared with the hospital's electronic voluntary event reporting system to identify whether these ADEs had been previously identified. The positive predictive values (PPVs) of the entire trigger tool and individual triggers were calculated to assess their accuracy to detect ADEs. RESULTS: Trigger occurrences (n = 706) were detected in 390 patients from 6 medication triggers, 33 of which were ADEs (overall PPV = 16%). Hyaluronidase had the greatest PPV (60%). Most ADEs were category E harm (temporary harm) per the National Coordinating Council for Medication Error Reporting and Prevention index. One event was category H harm (intervention to sustain life). Naloxone was associated with the most grade 4 ADEs per the Common Terminology Criteria for Adverse Events v4.03. Twenty-one (64%) ADEs were preventable, 3 of which were submitted via the voluntary reporting system. CONCLUSION: Most of the medication-based triggers yielded low PPVs. Refining the triggers based on patients' characteristics and medication usage patterns could increase the PPVs and make them more useful for quality improvement. To efficiently detect ADEs, triggers must be revised to reflect specialized pediatric patient populations such as hematology and oncology patients.

Using EHR Data to Detect Prescribing Errors in Rapidly Discontinued Medication Orders.

BACKGROUND: Previous research developed a new method for locating prescribing errors in rapidly discontinued electronic medication orders. Although effective, the prospective design of that research hinders its feasibility for regular use. OBJECTIVES: Our objectives were to assess a method to retrospectively detect prescribing errors, to characterize the identified errors, and to identify potential improvement opportunities. METHODS: Electronically submitted medication orders from 28 randomly selected days that were discontinued within 120 minutes of submission were reviewed and categorized as most likely errors, nonerrors, or not enough information to determine status. Identified errors were evaluated by amount of time elapsed from original submission to discontinuation, error type, staff position, and potential clinical significance. Pearson's chi-square test was used to compare rates of errors across prescriber types. RESULTS: In all, 147 errors were identified in 305 medication orders. The method was most effective for orders that were discontinued within 90 minutes. Duplicate orders were most common; physicians in training had the highest error rate (p < 0.001), and 24 errors were potentially clinically significant. None of the errors were voluntarily reported. CONCLUSION: It is possible to identify prescribing errors in rapidly discontinued medication orders by using retrospective methods that do not require interrupting prescribers to discuss order details. Future research could validate our methods in different clinical settings. Regular use of this measure could help determine the causes of prescribing errors, track performance, and identify and evaluate interventions to improve prescribing systems and processes.

BRINGING VALUE: HOW TO CREATE A SAFER SPACE FOR EVERYONE.

Learn why changing institutional culture is essential for the well-being of patients, practitioners and administrators alike.

Extracranial Cervical Artery Dissections.

Cervical artery dissections (CeAD) include both internal carotid and vertebral artery dissections. They are rare but important causes of stroke, especially in younger patients. CeAD should be considered in patients with strokelike symptoms, a new-onset headache and/or neck pain, and/or other risk factors. Early imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is key to making the diagnosis. Treatment may vary depending on the extent of the dissection, timing of the dissection, and other comorbidities. The overall prognosis is good, but does depend on the initial severity of symptoms.