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MEdIC Series: Case of the Not So Humorous Humerus

2017-01-04T18:32:43+00:00

ProfessionalismNotUnprofessionalism.  It is notoriously hard to define and dependent upon the eye of the beholder. And yet, as medical educators, we often are asked to intervene when it occurs.  Join our discussion on how to handle a case where a patient discloses to you, the supervising physician, that a resident has been less-than-professional. What would you do?

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them!

If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Not-so-Humorous Humerus

by Dr. Amy Walsh (@docamyewalsh); Edited by Dr. Teresa Chan

“Hey, do you have time to hear about one? I think we can get her out of here pretty quick,” said Sean, a third year resident.  “She seems kind of dramatic.  She was trying to get up from her chair last night, her legs got tangled and she fell.  She’s complaining of severe arm pain and says that she hasn’t been able to use it since the fall.  I think it’s just a deep bruise, but I can’t get a very good exam because she screams every time I touch her arm, so I guess I’ll get some x-rays.  Oh, and she has lupus, no other health problems.”

You walk into the room to staff the patient. Mrs. Johnson is obviously uncomfortable, but you understand Sean’s perception that she was dramatic. Armed with the x-ray, you have the benefit of information that your resident did not. Her years of chronic steroids had led to a proximal humerus fracture after relatively mild trauma. You finish up your history and exam, and inform Mrs. Johnson of the plan. “So, we’ll give the Orthopedic surgeon a call.  They’ll come see you, and you might need a surgery – but at the very least you might need adjustments to make sure you’re safe at home using your walker.  Can I get you some medicine for pain? ” you say, as you are leaving the room after staffing the patient.

“Yes, please.  Thank you so much for listening to me. I think Dr. Peters thought I was faking. It seemed like he was almost laughing at me when he was in here. He kept asking me what I was crying about, and trying to get me to get up and try walking.  I wouldn’t come here unless I was really in pain, so that made me pretty upset.” Mrs. Johnson said.

“Oh? I’m so sorry to hear that. We’ll make sure everyone takes excellent care of you from here on out, and I’ll discuss this with Dr. Peters.”

You step out of the patient’s room and see Sean putting in orders on another patient.  This seems to be a good time to have this discussion with him.

Key Questions

  1. How do you address the patient’s concerns with Sean?
  2. What do you expect of Sean to make it right with the patient?
  3. How do you work through the encounter to make it a learning experience for him, and to help him identify the behaviors that were offensive to the patient?
  4. How much do you delve into the resident’s personal issues that may be leading to compassion fatigue?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published on April 4, 2014.

Click HERE for a link to the Expert & Community responses, which include words from:

  • Dr. Felix Ankel (@FelixAnkel), the vice president and executive director of health professional education, HealthPartners Institute for Education and Research. Felix is a the current Accreditation Council for Graduate Medical Education (ACGME) designated institutional official for Regions Hospital in Saint Paul, MN. He is an associate professor and assistant dean at the University of Minnesota and serves on the board of directors for the Council of Emergency Medicine Residency Directors.
  • Dr. Anne Smith (@AnneStir), an emergency physician in George, South Africa. She works to serves a large rural district and loves exploring innovative ways to improve emergency care in areas that are challenged by great distances and resource limitation. Her areas of interest are ultrasound, patient safety and education.

 

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.  Also, as always, we will generate a curated community commentary based on your participation below and on Twitter.  We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Amy Walsh, MD

Amy Walsh, MD

International Emergency Medicine Fellow
Regions Hospital
St Paul, Minnesota
  • Breaking the ice… I think a big part of the approach to this issue will be to sit down with Sean and get his side of the situation. At times, both parties may have a different perception of the proceedings, so it is imperative to see what Sean the resident thinks. Hopefully, you may be able to encourage him to reflect on answers; and perhaps borrowing from literature around debriefing simulation, you might just report facts to him and ask him what his thoughts are as well.

  • amywalsh

    I wanted to share a bit about the inspiration for this case and a few thoughts on how I’d approach it now.

    First, this case was inspired by a couple of true stories from my intern year where I thought the patients had relatively minor injuries, but they ended up with quite severe, high energy injuries. In this case, I think my errors were more due to lack of experience rather than burnout/compassion fatigue, but the fact that these cases happened in fairly rapid succession have remained important reminders about compassion and bias throughout my career.

    As is the case in almost all MEdIC cases, I think understanding the resident’s mental/emotional state is vital. Burnout is a major reason we have lapses in empathy, and it is surely easy to get burnt out during residency. I think we often neglect that life continues to happen during residency so marriage and family problems, deaths in the family can and do impact our work.

    For me, a case like this is really an opportunity to explore our personal biases as doctors. It is well known that a patient’s pain is perceived differently based on race, age, and physical appearance. Cases like this are an important reminder that we get it wrong fairly often. Awareness of these cases can be a helpful reminder for similar cases in the future.

    I’m still fairly early in my career, so calling residents and students out on lapses in professionalism still requires generating a bit of nerve (probably still will in 20 years). I’ve been reflecting on a few possible approaches. I think that, if possible, allowing the resident/student the opportunity to share the diagnosis with the patient provides a natural opportunity to show empathy and apologize for a lack of empathy earlier. Otherwise, after exploring the factors that led us to underestimating this patient’s injuries, it is important to encourage the resident to try to mend their relationship with the patient. We have to apologize fairly often in our career, it can be helpful to develop those skills early, with the help of a mentor. With medical error, physicians feel less traumatized if they have the opportunity to disclose the error and apologize for it. I’d imagine this situation would be somewhat similar.

  • Michelle Gibson

    I have a question more than an answer – would the behavior of the resident (as reported by the patient) not have been considered unprofessional even if the patient didn’t have a fracture? (I assume everyone would say yes?) It’s easier to help residents learn from this sort of encounter when they missed something – it’s harder if they didn’t miss anything – except for missing the opportunity for the patient to have faith in the encounter. I think that’s where hidden curriculum has often played a big role – they’ve seen others (including attending physicians) behave similarly around patients who did not turn out to have a “legitimate” injury, etc, so they think it’s OK. I would just want to ensure the debrief made that point- even if the patient had not had a fracture, there is a level of care that is expected that was not met, per the patient’s account.

    I think this is the most interesting question: “What do you expect of Sean to make it right with the patient?” This is the biggest learning opportunity, I think. I have asked residents to address patient concerns about encounters. We usually talk about how to approach it before hand, and then I go in and directly observe. If they do a good job of this, I make sure they know that they handled it well. I think that it usually turns it into a very, very powerful learning experience and (in my opinion anyway…) may be the thing that is most likely to help it not happen again.

    Compassion fatigue or not (which absolutely needs to be explored) – we all have bad days, and knowing this, and recognizing it, and being able to acknowledge to our patients that we did not really meet the standards of our profession in a particular encounter is a very difficult but essential part of being a good physician. Because I do outpatient geriatrics, I have patients I see over long periods of time, and I will confess some of these relationship maybe didn’t start out perfectly (shocker!) – but if we have a good “clearing of the air” session, I usually end up with a great, if not better, doctor-patient-family relationship, and am often truly sorry when I am no longer following them.

    My 2 non-caffeinated cents anyway! Great case.

    • amywalsh

      Great point! Feeling mocked and disrespected is a problem no matter why you come to the ED or what is found in the evaluation. But you’re right, that teachable moment comes a lot more easily if there is something objective to show the lapse.

      I really like that you directly observe in these encounters. Residents need authentic feedback on how they handle these situations, which they can’t get any other way. And, as you said, when an apology is handled well it is usually leaves both patient and doctor feeling better than they did beforehand.

    • Thanks for your comment Michelle! And thanks for coming out to comment again! I do wonder if being ‘right’ makes people forgive unprofessionalism… (e.g. the stereotypical mean, but amazing physician or surgeon springs to my mind).

  • Well written, interesting scenario, Amy! As a civilian, I can’t comment from personal experience. But, as a researcher, I can mention the work of my colleague Dr. Chris Watling aka @ChrisWatling3 (Western, CNS; Associate Dean, Postgrad Medical Education). Chris has published a series of studies about feedback in medical education.

    To cite one of his studies I particularly enjoyed, Chris conducted a large qualitative study using interviews and focus across three “cultures of training”, music, education, and medicine. The main argument from this particular paper is that feedback is only effective insofar as the receiver considers the provider to be credible and constructive. Further, definitions of credibility and constructiveness vary according to the learning culture (e.g., a music teacher may be highly critical of a student’s posture, but that type of directness is valued in music; while a medical teacher may need to approach feedback in a different way, as we are discussing here).

    I’d extend this, as a social scientist, and argue that the local feedback culture is likely going to influence what constructive, credible feedback looks like at Sean’s hospital.

    Citation:

    Watling, C., Driessen, E., van der Vleuten, C. P., Vanstone, M., & Lingard, L. (2013). Beyond individualism: professional culture and its influence on feedback. Med Educ, 47(6), 585-594. doi: 10.1111/medu.12150

  • Nadim Lalani

    Good pearls from the community.

    My 2 cents:

    I think its a normal human reaction to have negative counter-transferance towards others that seem different [in this case “dramatic”]. Plus there is a commonly held myth that most people in the ER do not need to be there – so this often plays into the dynamic [Pt may have already been negatively labelled by other care-givers].

    Croskerry also talks about “attribution error” – when we minimise or invalidate complaints based on attributes of the patient “oh he’s a drug user so must be drug-seeking …”

    Negative counter-transferance and attribution error are 2 sure-fire ways to make mistakes in clinical thinking.

    Furthermore – being a good clinician is about more than simply making the diagnosis – therapy includes the human interaction. So there was room to acknowledge the patient’s distress, reassure her about the plan and call out the emotional component into the room. A more senior learner should have been able to do this.

    On the positive side: This interaction was a gift from the ER gods. There’s only one way to learn some skills in life. Mistakes like this offer the R3 an opportunity to learn and change.

    Plan: Get resident to see the above points. Heart-felt apology to patient for not actively listening and acknowledging. And move on [action/goal being more self-aware in the future]

    thanks
    Nadim

  • Tim Horeczko

    Great post, as always! I agree with Drs Gibson and Lalani and Mr McDougall — very well said.

    I will just add a brief note:

    This case paints a pretty clear picture of “villain and victim” — but many times the interaction between individuals and the inner workings of the individual himself clash or collude, almost to ensure a bad outcome. We’re all human, at the core we (the patient and provider) want what is best; we just have to recognize and deal with the many obstacles to good care.

    Sometimes we are just running low in empathy and need a serious self-check.

    Some patients are just not good self-advocates. In other words, we have all cared for those who interact with staff in such a way that triggers our natural human response to take it (whatever the interaction may be) personally. It’s important that we recognize that a) some people do themselves a disservice by their behavior (whether willfully or as a side effect of their active disease); and b) we can get sucked into the drama very easily.

    We all know this, but part of professionalism is realizing that “it’s not about you, it’s about them” — whether that be the cause of their ire or your focus on what is the best management plan.

    In short, let’s not be short with our patients: whether that is in their evaluation, management, or…in our attitude towards them. We’re human, it happens, we can all always improve, but let’s do ourselves and our patient a favor and focus on what you can do to make a positive difference in his life at that moment and precious opportunity that you have with him.

    Thanks again, Drs Walsh and Chang for a great discussion!

  • Great case and I think something that we sometimes see in our learners. I think one has to be a bit careful when approaching the learner, because we are assuming the patient is 100% accurate in the story they tell us. Sometimes patients “split” the providers and give different stories. That being said, in this case I would certainly pull the resident aside and ask how everything went. Get their own insight and feedback about how the interaction went. Then, you can discuss what information the patient provided you. This is a great opportunity to dive into why there might be a lack of empathy/sympathy for the patient. From fatigue to relationship issues to depression and substance abuse, there are lots of reasons learners might be behaving this way. Two things to think about here: 1. What might be the root cause of the behavior? (This has to be investigated/followed up) and 2. Use this as a teaching tool–that emotion and attitude is linked to misdiagnosis. We have all been in bad moods before, and we tend to behave differently under those circumstances.

    I would emphasize that we owe it to our learners to keep track of this behavior and not dismiss it as an isolated event, unless it really is. This might require discussing with the program director, etc. We owe it to our patients and our learners to make sure we are doing all we can to train competent professionals. Too many times we dismiss such isolated events and never follow up. Learners with significant issues can ‘slide under the radar” for quite sometime if we don’t stay on top of things.

    My 2 cents.

  • anne smith

    Great case Amy, certainly a tough situation for both educator and resident. Have enjoyed reading the comments and discussion thus far.

    To throw a new angle on this case: recently experienced a similar situation where it was not a resident that ‘mistreated’ the patient and made an error, but another attending (actually one of my senior attendings, has been at the hospital a lot longer than me). The case was brought to my attention by another junior doctor, which made the whole situation pretty awkward!

    Any thoughts from other junior faculty on how to handle this?

    • I think the challenges for a junior staff or senior resident are the same. I think maybe you might involve the chief of your emergency medicine service though.

      Real time debriefing is less possible for those who are no longer learners though, because often it will occur later, when a patient writes a complaint letter or calls the patient-advocate.

      This can complicate things as well, since the stakes are higher…

      How did you resolve the case?

      • anne smith

        Luckily the patient involved returned to the EC within 24 hours and was seen directly by me – one of the juniors picked up that there had been something missed and rightly escalated things. I gave the attending involved a quick call and to his credit he immediately came down and saw the patient himself!

  • Brent Thoma

    Sorry for being late to the party! A lot of really spectacular points.

    One thing I didn’t see extensively addressed was the approach to the difficult debrief. As noted in several of the comments, bringing this up with the resident is going to be a challenge. There is a high risk that any questions about this interaction will put the resident on the defensive and decrease the opportunity for learning.

    In Sim Land we spend a lot of time discussing this type of debrief. The best approach that I have seen comes from the Center for Medical Simulation out of Harvard/MGH. They advocate trying to approach the learner with a true sense of curiosity about what happened (faking it won’t work) and avoiding GWIT (Guess What I’m Thinking) questions by stating your opinion bluntly. This requires you to change your assumptions from the most obvious one in this case (that the resident was a jerk) to something more along the lines of (I wonder what happened?).

    In this case I would suggest a script that incorporates the facts, the preceptor’s perception of why it is a problem, and gives the learner an opportunity to explain:
    “Sean, I just went to see Mrs. Johnson. She mentioned that she was quite upset by her interaction because she didn’t think that you were taking her seriously. That’s concerning to me because if a patient leaves with that impression they are less likely to follow our directions or return if we make a mistake. What happened in there?”

    The fact is that Mrs Johnson didn’t feel that she was taken seriously, the attending’s concern is legitimate, and the learner is given an opportunity to reflect on their interaction without getting defensive because they have already been judged.

    Amy and Teresa – great case! Sorry for chiming in so late!

    -brent

  • Danica K

    Everyone has made really good points so far. Not sure what more of value I can add…

    Emergency is one of the most important places for patients to be treated with compassion (likely weren’t expecting to be there, long waits, confusion regarding what is happening
    to them, noise, uncertainty, pain, etc.). Unfortunately, it can also be the most difficult area for healthcare workers to be compassionate and patient.

    I should first say I don’t envy faculty in this position. Tricky situation and no matter how much preparation goes into the conversation, it will always be somewhat awkward and uncomfortable.

    I’d agree it’s important to get the resident’s side of things. As Dr. Rogers mentioned, sometimes there may be other issues, including “splitting” going on, and it may not have been as clear-cut unprofessionalism as the patient seems to think. Having said that, the patient still felt she wasn’t taken seriously, so even if the resident doesn’t think he was “un-compassionate”, he’ll need to take that feedback, process it, and do his own evaluation. It could also be the case that the resident himself is not quite happy with how the encounter went. Maybe he’s ruminating about it and upset he wasn’t as compassionate as he should have been. I think sometimes the harshest critics of students are the students themselves (….guilty).

    It’s never pleasant to receive negative feedback, but this type of negative feedback is often more difficult to take as a learner than others. It is one thing to not know the differential of something, the dosage of drug X, the value of blood test Y. It’s another thing entirely to be told your actions, your *professionalism*, were not up to par. The latter hits on who you are as a person, your personality. And it hurts a lot more than any knowledge deficit!

    Others have mentioned too about life events that may impact our work and performance. Although this issue has been gaining more and more attention in the past decades, I still think it is underappreciated. It is an extremely difficult skill to be able to block out “life” from our daily work and learning. I’ve yet to learn how to do it well (by any stretch) myself. I
    think it would be important to ask the resident about any issues. Keep in mind that he may not feel comfortable talking about them, if present. I remember a similar compassion/professionalism issue from the non-medical world where an employee was not performing as he used to. Upon being asked about it by a supervisor, he admitted to a minor problem/concern in his life, but was too embarrassed and uncomfortable to discuss the main issue. The supervisor couldn’t understand how such a seemingly minor issue
    would have such an impact on performance, and the employee continued to struggle for a bit until his real problem was dealt with.

    Also, keep in mind that those in glass houses shouldn’t throw stones. Humans of all stripes do this (…guilty again). I’ve seen students criticise other students when they’ve done similar things. And it sometimes happens with attendings and residents too. Though I’d like to sometimes think I’m an adult, all grown up and no longer as impressionable as a child, I know I’m not (Social Learning Theory for the win!!). I think as learners, we’re as influenced by the behaviour of attendings as the proverbial toddler learning to speak. Whenever we’re in teaching or leadership roles, we always have to remember: “Your actions speak so loudly, I cannot hear what you’re saying.” – Ralph Waldo Emerson

    And perhaps most importantly (as Dr. Lalani mentioned), move on.