Do Emergency Medicine Residents Prefer Resident-initiated or Attending-initiated Feedback?

BACKGROUND: Real-time feedback is crucial to improving physician performance. Emerging theory suggests that learner-initiated feedback may be more effective in changing performance than attending-initiated feedback, but little is known about how residents perceive resident- versus attending-initiated feedback. OBJECTIVES: The primary aim was to determine whether residents' satisfaction varied by learner-versus attending-initiated feedback encounters. We hypothesized that residents would be more satisfied with resident-initiated feedback. METHODS: This was a multicenter study of five emergency medicine residency programs. We developed a milestones-based, real-time feedback intervention that provided behavioral anchors for ED subcompetencies and prompted a feedback discussion. The intervention was implemented at all sites for a 3-month period from March to November 2014. Residents were asked to initiate one card per shift; attendings were also invited to initiate encounters and, in either instance, asked to provide one specific suggestion for improvement. Residents confidentially rated their satisfaction with feedback on a 10-point scale. Reported satisfaction was categorized as "very satisfied" (score of 10) versus "less than very satisfied" (score < 10). Logistic regression was used to assess the difference in satisfaction between resident- versus attending-initiated feedback, and random effects were used to account for the clustering of repeated ratings within resident and by site. RESULTS: A total of 785 cards was collected from five sites. Participation varied by site (range = 21-487 cards per site). Of the 587 cards with both feedback initiator and satisfaction data, 67% (396/587) were resident-initiated, and median satisfaction score was 10 (range = 4-10). There was no difference in the odds of being "very satisfied" by resident- vesus attending-initiated encounters (odds ratio = 1.08, 95% confidence interval = 0.41 to 2.83). CONCLUSIONS: Our results suggest that residents are likely to be as satisfied with self-initiated feedback as attending-initiated feedback. Further research is needed to determine whether resident-initiated feedback is more likely to be incorporated into practice and result in objective performance improvements.

Clinical pathologic conference: a 51-year-old man with rash and joint pain.

The authors present a case of a 51-year-old male who arrived to the emergency department (ED) with rash and arthralgias. He was not initially forthcoming about all aspects of his history, but ultimately careful clinical evaluation confirmed by laboratory abnormalities revealed the diagnosis. The patient's clinical presentation is given, a discussion of the differential diagnoses is included, and his clinical course is summarized.

Lack of early defibrillation capability and automated external defibrillators in nursing homes.

OBJECTIVE: To determine the availability of early defibrillation and automated external defibrillators in nursing homes in selected cities. DESIGN: A standardized telephone survey was conducted of all skilled nursing facilities to characterize early defibrillation capabilities. SETTING: The study involved nursing homes in Philadelphia, Omaha, Seattle, and Boston. PARTICIPANTS: All skilled nursing facilities not physically attached to hospitals in the selected cities based on listings from the Centers for Medicare and Medicaid Services as of January 2004. MEASUREMENTS: Each site was queried as to whether or not they had an automated external defibrillator (AED), if they were physically freestanding facilities, if a manual defibrillator was present, and if staff were present 24 hours a day to use the defibrillator. Early defibrillation was defined as the presence of either a manual defibrillator or AED in addition to 24-hour trained staff availability. RESULTS: There were 126 nursing homes identified from the Medicare listing and 81% (102) responded to our phone survey. After exclusion of non-freestanding facilities, 90 nursing homes (71.4%) were available for analysis. Overall, 16.7% (95% CI 8.8-24.5) of nursing homes reported early defibrillation capabilities via manual defibrillator or AEDs; 6.7% (95% CI 1.4-11.9) of nursing homes reported AEDs; 10.0% (95% CI 3.7-16.3) of nursing homes reported manual defibrillators. Nursing homes in Seattle had a higher rate of early defibrillation capability than the other 3 cities. CONCLUSION: Despite the fact that nursing homes have been identified as locations with multiple cardiac arrests, the early defibrillation capabilities and prevalence of AEDs in this setting remains low. AEDs may play a role in improving survival from cardiac arrest in nursing homes. The placement of AEDs in nursing homes needs further consideration and study.