"Two Years Later I'm Still Just as Angry": A Focus Group Study of Emergency and Internal Medicine Physicians on Disrespectful Communication.

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.

What gets resident physicians stressed and how would they prefer to be supported? A best-worst scaling study.

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.

Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery.

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 .

Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage.

BACKGROUND: Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI). METHODS: Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016-12/2018. INCLUSION CRITERIA: head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm). EXCLUSION CRITERIA: GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion. OUTCOMES: pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits. RESULTS: 138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/- 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/- 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring. CONCLUSIONS: ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting.

A Model for Electronic Handoff Between the Emergency Department and Inpatient Units.

BACKGROUND: Patient handoffs between units can introduce risk and time delays. Verbal communication is the most common mode of handoff, but requires coordination between different parties. OBJECTIVE: We present an asynchronous patient handoff process supported by a structured electronic signout for admissions from the emergency department (ED) to the inpatient medicine service. METHODS: A retrospective review of patients admitted to the medical service from July 1, 2011 to June 30, 2015 at a tertiary referral center with 520 inpatient beds and 57,000 ED visits annually. We developed a model for structured electronic, asynchronous signout that includes an option to request verbal communication after review of the electronic handoff information. RESULTS: During the 2010 academic year (AY) all admissions used verbal communication for signout. The following academic year, electronic signout was implemented and 77.5% of admissions were accepted with electronic signout. The rate increased to 87.3% by AY 2014. The rate of transfer from floor to an intensive care unit within 24 h for the year before and 4 years after implementation of the electronic signout system was collected and calculated with 95% confidence interval. There was no statistically significant difference between the year prior and the years after the implementation. CONCLUSIONS: Our handoff model sought to maximize the opportunity for asynchronous signout while still providing the opportunity for verbal signout when deemed necessary. The process was rapidly adopted with the majority of patients being accepted electronically.

Consensus of the Millennium Conference on Teaching High Value Care.

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.

The Integration of Electronic Medical Student Evaluations Into an Emergency Department Tracking System is Associated With Increased Quality and Quantity of Evaluations.

BACKGROUND: Medical student evaluations are essential for determining clerkship grades. Electronic evaluations have various advantages compared to paper evaluations, such as increased ease of collection, asynchronous reporting, and decreased likelihood of becoming lost. OBJECTIVES: To determine whether electronic medical student evaluations (EMSEs) provide more evaluations and content when compared to paper shift card evaluations. METHODS: This before and after cohort study was conducted over a 2.5-year period at an academic hospital affiliated with a medical school and emergency medicine residency program. EMSEs replaced the paper shift evaluations that had previously been used halfway through the study period. A random sample of the free text comments on both paper and EMSEs were blindly judged by medical student clerkship directors for their helpfulness and usefulness. Logistic regression was used to test for any relationship between quality and quantity of words. RESULTS: A total of 135 paper evaluations for 30 students and then 570 EMSEs for 62 students were collected. An average of 4.8 (standard deviation [SD] 3.2) evaluations were completed per student using the paper version compared to 9.0 (SD 3.8) evaluations completed per student electronically (p < 0.001). There was an average of 8.8 (SD 8.5) words of free text evaluation on paper evaluations when compared to 22.5 (SD 28.4) words for EMSEs (p < 0.001). A statistically significant (p < 0.02) association between quality of an evaluation and the word count existed. CONCLUSIONS: EMSEs that were integrated into the emergency department tracking system significantly increased the number of evaluations completed compared to paper evaluations. In addition, the EMSEs captured more "helpful/useful" information about the individual students as evidenced by the longer free text entries per evaluation.

Implementation of an emergency department sign-out checklist improves transfer of information at shift change.

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.

Practicing emergency physicians report performing well on most emergency medicine milestones.

BACKGROUND: The Accreditation Council for Graduate Medical Education's Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings. OBJECTIVE: Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones. METHODS: An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them. RESULTS: Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001). CONCLUSIONS: Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

Prospective evaluation of daily performance metrics to reduce emergency department length of stay for surgical consults.

BACKGROUND: As part of a quality improvement initiative to reduce Emergency Department (ED) length of stay (LOS) for surgical consult patients, we e-mailed performance metrics to key stakeholders on a daily basis. ED and Surgery leadership used these daily metrics to identify and remedy contributing factors for increased ED LOS in patients who received surgical consults. OBJECTIVE: To evaluate whether a quality improvement process driven by a daily performance metric e-mail would be associated with a change in ED LOS for surgical consult patients. METHODS: Prospective before-after study looking at ED LOS for surgical consult patients after an e-mail intervention at a tertiary academic teaching hospital. All consecutive adult ED patients between July 1, 2010 and October 1, 2010 who received a general surgical consult were enrolled. The primary outcome measure was ED LOS, and secondary outcome measure was time to consultation. RESULTS: There were 916 patients who had surgical consults placed during the study period; 459 patients presented before the intervention and 457 patients presented after the intervention. The median LOS decreased 54 min, from 463 min (interquartile range [IQR] 326-617) before the intervention to 409 min (IQR 294.5-528.5) after the intervention (p < 0.001). Time to consultation decreased 25 min, from a median of 160 min (IQR 87-265) to 135 min (IQR 70-239.5) (p = 0.002). There was no difference in age, severity, number of consults, or disposition. There was also no difference in median LOS for other consultation services or in previous years during the same time period. CONCLUSIONS: ED LOS and time to consultation were decreased for surgical consult patients after initiation of daily performance metric e-mails.