Ecological interchangeability: supporting team adaptive expertise in moments of disruption.

While undesirable, unexpected disruptions offer unique opportunities to enact adaptive expertise. For adaptive expertise to flourish, individuals and teams must embrace both efficiency and adaptation. While some industries do it readily, others continue to struggle with the tension between efficiency and adaptation, particularly when otherwise stable situations are unexpectedly disrupted. For instance, in healthcare settings, the efficiency mandate for strict compliance with scopes of practice can deter teams from using the adaptive strategy of making their members interchangeable. Yet, interchangeability has been hinted as a key capacity of today' teams that are required to navigate fluid team structures. Because interchangeability - as an adaptive strategy - can generate antagonistic reactions, it has not been well studied in fluid teams. Thus, in this exploratory qualitative study we sought to gain insights into how interchangeability manifests when fluid teams from five different contexts (healthcare, emergency services, orchestras, military, and business) deal with disruptive events. According to our participants, successful interchangeability was possible when people knew how to work within one's role while being aware of their teammates' roles. However, interchangeability included more than just role switching. Interchangeability took various forms and was most successful when teams capitalized on the procedural, emotional, and social dimensions of their work. To reflect this added complexity, we refer to interchangeability in fluid teams as Ecological Interchangeability. We suggest that ecological interchangeability may become a desired feature in the training of adaptive expertise in teams, if its underlying properties and enabling mechanisms are more fully understood.

"All Patients Are Not Treated as Equal": Extending Medicine's Social Contract to Black/African American Communities.

PHENOMENON: The social contract is an implicit agreement that governs medicine's values, beliefs, and practices in ways that uphold the profession's commitment to society. While this agreement is assumed to include all patients, historical examples of medical experimentation and mistreatment suggest that medicine's social contract has not been extended to Black patients. We suggest that is because underlying medicine's contract with society is another contract; the racial contract, which favors white individuals and legitimizes the mistreatment of those who are nonwhite. When Black/African American physicians enter medicine, they enter into the social contract as an agreement with society, but must navigate the realities of the racial contract in ways that have yet to be acknowledged. This study examines how Black/African American physicians interpret and enact the social contract in light of the country's racial contract by investigating the ways in which Black/African American physicians discuss their interactions with Black patients. APPROACH: This qualitative study reexamines cross-sectional data previously collected in 2018-2019 examining the professional identity formation (PIF) experiences of Black/African American trainees and physicians in the Southern part of the U.S. The goal of the larger study was to explore participants' professional identity formation experiences as racialized individuals within a predominantly white profession. The current study examines these data in light of medicine's social contract with society and Mill's (1997) theory of the racial contract to understand how Black physicians interpret and enact the social contract. Participants included 10 Black/African American students, eight residents, and nine attending physicians. FINDINGS: The findings show that Black/African American physicians and trainees are aware of the country's racial contract, which has resulted in Black patients being historically excluded from what has been described in the social contract that governs all physicians. As such, they are actively working to extend the social contract so that it includes Black patients and their communities. Specifically, they engage in trust building with the Black community to make sure all patients are included. Building trust includes ensuring a consistent stream of new Black/African American trainees, and equipping Black trainees and patients with the skills needed to improve the healthcare within the Black/African American community. INSIGHTS: While it been has assumed that all patients are included in the social contract between medicine and society, historical examples of medical mistreatment and experimentation demonstrate this is inaccurate; Black/African American communities have not been included. In an effort to dismantle systemic racism in the U.S., medical education must teach about its racist past and divulge how some communities have been historically excluded, providing new ways to think about how to include everyone in medicine's social contract.

Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

OBJECTIVES: Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS: A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS: This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS: Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

The fatigue paradox: Team perceptions of physician fatigue.

OBJECTIVES: Ongoing calls to implement fatigue risk management in residency education assume a shared understanding of physician fatigue as a workplace hazard, yet we lack empirical evidence that all health care team members maintain this assumption. Thus, this study seeks to explore how health care team members understand the role of physician fatigue in an effort to inform the implementation of fatigue risk management in residency training and medical practice. METHODS: This study uses constructivist grounded theory to explore perceptions of workplace fatigue and its impact on clinical practice. We conducted individual semi-structured interviews with physicians, nurses and senior residents across four hospitals in 8 different specialties for a total of 40 participants. Constant comparative analysis guided data analysis and led to the final grounded theory. RESULTS: While participants outlined multiple problematic manifestations of physician fatigue on clinical performance, they were reluctant to acknowledge any negative impact of fatigue on patient care. We refer to these contradictions as the fatigue paradox. Four key themes sustain the fatigue paradox: the indefatigable physician, blind spots, faith in safety nets and the minimisation of fatigue-related events. CONCLUSIONS: This study suggests that health care team members do not universally feel that physician fatigue is problematic for patient care, despite providing multiple examples to the contrary. This paradoxical understanding of fatigue likely exists because the system relies on fatigued physicians, particularly trainees, and provides few mechanisms to critically examine fatigue. Successful implementation of fatigue risk management in residency training may prove elusive if clinical supervisors are skeptical of the potentially negative impact of workplace fatigue.

"Changing the narrative": a study on professional identity formation among Black/African American physicians in the U.S.

Professional identity formation (PIF) is considered a key process in physician development. However, early PIF research may have inadvertently left out experiences from ethnically/racially minoritized physicians. As a result, the PIF literature may have forwarded dominant perspectives and assumptions about PIF that does not reflect those of minoritized physicians. This study used a cross-sectional study design, in which interview data was initially collected using constructivist grounded theory and then analyzed using critical lenses. Participants included 14 Black/African American students, 10 residents, and 17 attending physicians at two Southern medical schools in the U.S. Coding included the both/and conceptual framework developed out of Black feminist scholarship, and further analyzed using medicine's culture of Whiteness. These lenses identified assumptions made in the dominant PIF literature and how they compared to the experiences described by Black physicians. The results show that medical education's historical exclusion of minoritized physicians in medical education afforded a culture of Whiteness to proliferate, an influence that continues to frame the PIF research. Black physicians described their professional identity in terms of being in service to their racial/ethnic community, and the interconnectedness between personal/professional identities and context. Their professional identity was used to challenge larger social, historical, and cultural mistreatment of Black Americans, findings not described in the dominant PIF research. Black physicians' experiences as minoritized individuals within a culture of Whiteness reveals that the PIF literature is limited, and the current framings of PIF may be inadequate to study minoritized physicians.

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.

Four-week cold acclimation in adult humans shifts uncoupling thermogenesis from skeletal muscles to brown adipose tissue.

KEY POINTS: Muscle-derived thermogenesis during acute cold exposure in humans consists of a combination of cold-induced increases in skeletal muscle proton leak and shivering. Daily cold exposure results in an increase in brown adipose tissue oxidative capacity coupled with a decrease in the cold-induced skeletal muscle proton leak and shivering intensity. Improved coupling between electromyography-determined muscle activity and whole-body heat production following cold acclimation suggests a maintenance of ATPase-dependent thermogenesis and decrease in skeletal muscle ATPase independent thermogenesis. Although daily cold exposure did not change the fibre composition of the vastus lateralis, the fibre composition was a strong predictor of the shivering pattern evoked during acute cold exposure. ABSTRACT: We previously showed that 4 weeks of daily cold exposure in humans can increase brown adipose tissue (BAT) volume by 45% and oxidative metabolism by 182%. Surprisingly, we did not find a reciprocal reduction in shivering intensity when exposed to a mild cold (18°C). The present study aimed to determine whether changes in skeletal muscle oxidative metabolism or shivering activity could account for these unexpected findings. Nine men participated in a 4 week cold acclimation intervention (10°C water circulating in liquid-conditioned suit, 2 h day-1 , 5 days week-1 ). Shivering intensity and pattern were measured continuously during controlled cold exposure (150 min at 4 °C) before and after the acclimation. Muscle biopsies from the m. vastus lateralis were obtained to measure oxygen consumption rate and proton leak of permeabilized muscle fibres. Cold acclimation elicited a modest 21% (P < 0.05) decrease in whole-body and m. vastus lateralis shivering intensity. Furthermore, cold acclimation abolished the acute cold-induced increase in proton leak. Although daily cold exposure did not change the fibre composition of the m. vastus lateralis, fibre composition was a strong predictor of the shivering pattern evoked during acute cold. We conclude that muscle-derived thermogenesis during acute cold exposure in humans is not only limited to shivering, but also includes cold-induced increases in proton leak. The efficiency of muscle oxidative phosphorylation improves with cold acclimation, suggesting that reduced muscle thermogenesis occurs through decreased proton leak, in addition to decreased shivering intensity as BAT capacity and activity increase. These changes occur with no net difference in whole-body thermogenesis.

How do residents respond to uncertainty with peers and supervisors in multidisciplinary teams? Insights from simulations with epistemic fidelity.

BACKGROUND: Residents struggle to express clinical uncertainty, often exhibiting negative cognitive, behavioral, and emotional responses to uncertainty when engaging with patients or supervisors. However, the Integrative Model of Uncertainty Tolerance posits that individuals may have positive or negative responses to perceived uncertainty. Situational characteristics, such as interactions with other health professionals, can impact whether the response is positive or negative. The team context in which residents interact with resident peers and supervisors could represent varying situational characteristics that enable a spectrum of responses to uncertainty. Understanding the situational characteristics of multidisciplinary teams that allow residents to display positive responses to perceived uncertainty could inform strategies to foster positive responses to uncertainty in other contexts. We explored resident responses to perceived uncertainty in a simulated multidisciplinary team context. METHODS: A simulation-primed qualitative inquiry approach was used. Fourteen residents from Cardiology and Obstetrics and Gynecology participated in simulation scenarios involving pregnant patients with heart disease. We incorporated epistemic fidelity through the deliberate inclusion of ambiguity and complexity to prompt uncertainty. Audio recordings of debriefing sessions were analyzed using directed content analysis. RESULTS: Residents recognized that uncertainty is unavoidable, and positive responses to uncertainty are crucial to team dynamics and patient safety. While residents had positive responses to expressing uncertainty to peers, they had predominantly negative responses to expressing uncertainty to supervisors. Predominant negative response to supervisors related to judgement from supervisors, and impacts on perceived trustworthiness or independence. Although residents recognized expressing uncertainty to a supervisor could identify opportunities for learning and resolve their uncertainty, the negative responses overshadowed the positive responses. Residents highly valued instances in which supervisors were forthcoming about their own uncertainty. CONCLUSIONS: Through participation in simulations with epistemic fidelity, residents reflected on how they perceive and respond to uncertainty in multidisciplinary teams. Our findings emphasize the role of situational characteristics, particularly peers and supervisors, in moderating responses to perceived uncertainty. The productive discussions around responses to uncertainty in debriefing sessions suggest further studies of multidisciplinary simulations could enhance our understanding of how uncertainty is expressed, and potentially be used as an instructional intervention to promote positive responses to uncertainty.

"The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses.

BACKGROUND: Although speaking up is lauded as a critical patient safety strategy, it remains exceptionally challenging for team members to enact. Existing efforts to address the problem of silence among interprofessional teams involve training low-authority members to use direct language and unambiguous challenge scripts. The role or value of indirect communication in preventing medical error remains largely unexplored despite its pervasiveness among interprofessional teams. This study explores the role of indirect challenges in the face of medical error and professionalism lapses. METHODS: Obstetricians at one academic center participated in an interprofessional simulation as a partial actor. Thirteen iterations were completed with 39 participants (13 obstetrician consultants, 11 obstetric residents, 2 family medicine consultants, 5 midwives, and 8 obstetrical nurses). Thirty participants completed a subsequent semi-structured interview. Five challenge moments were scripted for the obstetrician involving deliberate clinical judgment errors or professionalism infractions. Other participants were unaware of the obstetrician's partial actor role. Scenarios were videotaped; debriefs and interviews were audio-recorded and transcribed verbatim and analyzed using a constructivist qualitative approach. RESULTS: Low-authority team members primarily relied on indirect challenge scripts to promote patient safety during simulation. Faculty participants were highly receptive to indirect challenges from low-authority team members, particularly in front of awake patients. In the context of obstetric care, direct challenges were actually viewed by participants as threatening to patient trust and disruptive to the interprofessional team. Instead of exclusively focusing our efforts on encouraging low-authority team members to speak up through direct challenges, it may be fruitful to expand our attention toward teaching faculty to identify, listen for, and respond to the indirect, subtle challenges that are already prolific among interprofessional teams.

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design.

OBJECTIVES: To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes. DESIGN: An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques. SETTING: Canadian U SPORTS universities (n=56). PARTICIPANTS: Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews. OUTCOME MEASURES: Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course. RESULTS: Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min). CONCLUSIONS: The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.

Adapting despite "walls coming down": Healthcare providers' experiences of COVID-19 as an implosive adaptation.

INTRODUCTION: The COVID-19 pandemic has been a daunting exercise in adaptation for healthcare providers. While we are beginning to learn about the challenges faced by teams during the COVID-19 pandemic, what remains underexplored are the strategies team members used to adapt to these challenges. The goal of this study is therefore to explore how healthcare providers navigated and adapted to on-the-ground challenges imposed by COVID-19. METHODS: We interviewed 20 healthcare workers at various hospitals in Ontario, who provided care as part of clinical teams during the COVID-19 pandemic. Data were collected and analyzed following Constructivist Grounded Theory principles including iteration, constant comparison and theoretical sampling. RESULTS: Participants' accounts of their experiences revealed the process of 'implosive adaptation'. The 'reality check', the 'scramble' and the 'pivot' comprised this process. The reality check described the triggers, the scramble detailed the challenges they went through and the pivot prescribed the shifting of mindset as they responded to challenges. These stages were iterative, rather than linear, with blurred boundaries. DISCUSSION: According to our participants, not all adaptations have to be successful during a crisis. The language of reality check, scramble and pivot provides a framework for teams to talk about and make sense of their approaches to crisis, even beyond the COVID-19 pandemic.

Primary sclerosing cholangitis: A new case of cirrhosis in pregnancy.

Cirrhosis is a multisystemic condition in which pregnancy is uncommon; however, the combination may lead to a higher incidence of spontaneous fetal loss and complications such as progressive jaundice, ascites and variceal bleeding. Here we present a 21-year-old woman who presented at 14 weeks' gestation with new jaundice and a two-month history of melena consistent with pre-existing cirrhosis of unclear aetiology. She delivered a healthy male infant at 34 weeks and five days of gestation vaginally with good haemostasis. In the literature, maternal mortality rates have been reported in up to 61% of these women, however, this risk is likely lower now with modern endoscopic therapies and improved access to blood products. There is limited information about labour and delivery in cirrhosis, although the best outcomes to date have been described in well-compensated women.

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.

"Maybe I'm not that approachable": using simulation to elicit team leaders' perceptions of their role in facilitating speaking up behaviors.

BACKGROUND: Simulation research that seeks to solve the problem of silence among interprofessional teams has focused almost exclusively on training subordinate team members to be more courageous and to speak up to team leaders using direct challenge scripts despite the great interpersonal cost. Consequently, the existing literature overemphasizes the responsibility of subordinate team members for speaking up and fails to consider the role and responsibilities of team leaders in sustaining silence. The purpose of this study is to identify and describe the subtle behaviors and actions of team leaders that both promote and discourage speaking up. METHODS: This study used a simulation-primed qualitative inquiry approach. Obstetricians (OB) at one academic center participated in an interprofessional simulation as an embedded participant. Five challenge moments (CM) were scripted for the OB involving deliberate clinical judgment errors or professionalism infractions. Other participants were unaware of the OB embedded participant role. Thirteen iterations were completed with 39 participants. Twelve faculty members completed a subsequent semi-structured interview. Scenarios were videotaped; debriefs and interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic approach. RESULTS: After participating in an interprofessional simulation, faculty participants reflected that being an approachable team leader requires more than simply avoiding disruptive behaviors. We found that approachability necessitates that team leaders actively create the conditions in which team members perceive that speaking up is welcomed, rather than an act of bravery. In practice, this conceptualization of approachability involves the tangible actions of signaling availability through presence, uncertainty through thinking aloud, and vulnerability through debriefing. CONCLUSIONS: By using faculty as embedded participants with scripted errors, our simulation design provided an ideal learning opportunity to prompt discussion of the subtle behaviors and actions of team leaders that both promote and discourage speaking up. Faculty participants gained a new appreciation that their actions create the conditions for speaking up to occur before critical incidents through their verbal and non-verbal communication.

Patterns and trends among physicians-in-training named in civil legal cases: a retrospective analysis of Canadian Medical Protective Association data from 1993 to 2017.

BACKGROUND: Medico-legal data show opportunities to improve safe medical care; little is published on the experience of physicians-in-training with medical malpractice. The purpose of this study was to examine closed civil legal cases involving physicians-in-training over time and provide novel insights on case and physicians characteristics. METHODS: We conducted a retrospective descriptive study of closed civil legal cases at the Canadian Medical Protective Association (CMPA), a mutual medico-legal defence organization for more than 105 000 physicians, representing an estimated 95% of physicians in Canada. Eligible cases involved at least 1 physician-in-training and were closed between 1993 and 2017 (for time trends) or 2008 and 2017 (for descriptive analyses). We analyzed case rates over time using Poisson regression and the annualized change rate. Descriptive analyses addressed case duration, medico-legal outcome and patient harm. We explored physician specialties and practice characteristics in a subset of cases. RESULTS: Over a 25-year period (1993-2017), 4921 physicians-in-training were named in 2951 closed civil legal cases, and case rates decreased significantly (ß = -0.04, 95% confidence interval -0.05 to -0.03, where ß was the 1-year difference in log case rates). The annualized change rate was -1.1% per year. Between 2008 and 2017, 1901 (4.1%) of 45 967 physicians-in-training were named in 1107 civil legal cases. Cases with physicians-in-training generally involved more severe patient harm than cases without physicians-in-training. In a subgroup with available information (n = 951), surgical specialties were named most often (n = 531, 55.8%). INTERPRETATION: The rate of civil legal cases involving physicians-in-training has diminished over time, but more recent cases featured severe patient harm and death. Efforts to promote patient safety may enhance medical care and reduce the frequency and severity of malpractice issues for physicians-in-training.