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MEdIC Series: The Case of the Humorous Humerus – Expert Review and Curated Commentary

2016-12-15T15:08:14+00:00

The Case of the Not-So-Humorous Humerus presented an attending faced with a patient complaint about a resident. This is a situation that all of us will almost certainly be faced with at one point or another and there is no easy way to address it. This month we asked you to tell us how you would approach this difficult conversation to successfully determine what the problem was and how it should be addressed.

This month Dr. Amy Walsh (@docamyewalsh) and I (@TChanMD) explored this issue with insights from the ALiEM community and 2 experts.

This follow-up post includes

  • The responses of our medical education experts, Drs. Felix Ankel and Anne Smith
  • A summary of insights from the ALiEM community derived from the Twitter  and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert response 1: Compassion Fatigue & Feedback

Felix Ankel, MD
VP and Executive Director, Health Professional Education, HealthPartners Institute

This case is common and offers the learner a teachable moment in communication and situational awareness and the teacher an opportunity to hone the skills of feedback, cadence, and maintenance of boundaries.

Jack Ende’s 1983 JAMA article “Feedback in Clinical Medical Education” remains a classic and offers eight goals of effective clinical feedback (1). He suggests that feedback should:

  1. Be undertaken with the teacher and trainees working as allies with common goals
  2. Be well-timed and expected
  3. Be based on first-hand data
  4. Be in small quantities and limited to behaviors that can be remediated
  5. Be in descriptive non-evaluative language
  6. Deal with specifics, not generalities
  7. Offer subjective data labeled as such
  8. Deal with decisions and actions, rather than intentions or interpretations

Communication with the resident in this case may be influenced by the opening and cadence of the feedback. Consider opening with a soft invitation for feedback. For example:  “Can I give you some feedback based on the information I received from Mrs. Johnson”.  If an agreement to discuss Mrs. Johnson has been reached, I suggest limiting the feedback to the facts of the case and ask for Dr. Peter’s reflection. Based on the reflection, the attending may see the depth of Dr. Peter’s insight and adjust the cadence of subsequent feedback.

If Dr. Peters shows deep insight, I suggest the attending coach the resident on the anatomy of a patient apology and have a further discussion after the shift. This would be a better time to discuss compassion fatigue and situational awareness. Depending on the circumstance, a more in depth discussion could open the door to further discussion on depression, substance abuse, and personal relational challenges. If Dr. Peters shows limited insight, the attending should set guidelines for expected behaviors with clear consequences and discuss his concerns with the program director if continued communication issues occur.

Some programs are attempting a residency culture shift towards compassion through design thinking (2). Some have incorporated Schwartz Center rounds (3,4), an interdisciplinary forum where attendees discuss psychosocial and emotional aspects of patient care (5). Others have partnered with the Institute of Patient and Family Centered Care(6), which offers resources and patient advisors to programs wishing to embark on a patient centered journey.  Ultimately the combination of a residency culture focused on compassion with consistent 1:1 individual resident feedback will lead to residents with superior patient communication skills.

References

  1. Ende J.  Feedback in clinical medical education. JAMA 1983 250:777-781.
  2. Design Thinking, Wikipedia.
  3. Lown B, Manning MA. The Schwartz Center Rounds: Evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Academic Medicine 2010 85:1073-1080. PMID 20505412.
  4. Schwartz Center Rounds. The Schwartz Center. Retrieved on March 17, 2014.
  5. Ankel, F. Royal College Program Director Podcast. International Conference on Residency Education. Retrieved on March 17, 2014.
  6. Institute for Patient and Family Centered Care. Retrieved on March 17, 2014.
  7. Fox R. Cultural Competence and the Culture of Medicine. NEJM 2005:353;1315-1319
Expert response 2: Seven Tips for Improving the Patient Experience

Anne Smith MBChB  FCEM(SA)  MMed
Emergency Physician and Educator, Cape Town, South Africa

The discussion points in this case hinge around three main topics:

Patient expectations

Patient expectations vary with age, gender, cultural background and previous medical history. Some expect or associate physical touch with a more ‘caring’ doctor, while others would prefer not to be touched unless being examined. Some prefer a more conversational style of consultation while others would engage more with a more formal, fact based type of consultation.

One of the skills we must learn as EM clinicians is how to quickly make our patients feel comfortable and trusting of our clinical skill and decisions. We don’t have the luxury of time to build long term relationships – we are expected to delve into peoples’ most intimate secrets after only a few minutes! We work in clinical areas that are often busy, noisy, filled with distractions and not very private. Our attitudes and personal communication skills go a long way towards putting our patients at ease.

Our patients have right not only to excellent medical care and appropriate diagnoses, but also to a pleasant human experience while in our care.

Doctors attitudes

Sometimes it is hard to explain why we feel the way we do towards our patients.  We need to be aware of how our own prejudices and personal issues may affect our consultation and decision making skills. If we are is tired, hungry or had a previous negative experience with a particular type of patient, this may adversely affect their attitude towards them.

Compassion fatigue may result from external factors (long working hours or heavy on call duties) and internal factors (personal mental health issues or physical illness). It is our responsibility as educators and mentors to watch for evidence of compassion fatigue in those working with us and to address problems before patients suffer.

Cognitive errors

We all make cognitive errors during consultation, particularly when we lapse into intuitive thinking rather than deliberative thinking.  These errors may get worse in busy units, or with physical stressors like lack of sleep.

One example of a cognitive error in this case is anchoring, or anchor bias: Sean may have decided early on this consultation that she didn’t have a fracture and that the x-ray would be done simply to appease the patient. He may have neglected looking for other potential complications that a fracture could cause as he had already decided this was a ‘deep bruise’.

In summary

You can try some of the following to improve your patient experience:

  1. Introduce yourself and your role in the ED: It sounds simple, but it is easily forgotten.
  2. Ensure that the patient is comfortable before you start your consultation and try maintain their dignity and privacy as much as possible,
  3. Listen to the patient and let them tell the story in their own words. This can be frustrating, but interrupting and asking closed-ended questions may cause us to miss critical information.
  4. Practice self-reflection: During and after the consultation, ask yourself how you think it is going/went and what the patient is experiencing. Note any irritation or distraction in yourself and try to pinpoint why you are feeling that way and how it is affecting your patient contact.  Physical stressors like hunger and tiredness, as well as psychological stressors like a full waiting room may impact your bedside manner.
  5. Practice with simulation: This case  could easily be practiced in a role-play or simulation scenario.
  6. Beware of ‘difficult’ patients: Patients labeled or perceived as ‘dramatic’, ‘demanding’ or ‘uncooperative’ can blind us to their actual pathology and prevent us from getting a good history and examination.
  7. Use checklists, mental ‘checkpoints’ and senior advice to prevent or minimize cognitive error.

References

  1. Croskerry P, Abbass A, Wu AW.  Emotional influences in patient safety. J Patient Saf. 2010 Dec;6(4):199-205.
  2. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.
  3. Block L, Hutzler L, Habricht R, Wu AW, Desai SV, Novello SK, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. J Hosp Med. 2013 Nov;8(11):63-4.
The Case of the Not so Humorous Humerus: Curated from the community

Curated by Teresa Chan

The following are some themes that emerged from our discussion in the case comments for this past week.

1. Explore the resident’s point of view and context

Unless there was a CCTV camera in the room, you’re probably never going to really know what happened between Sean and his patient, but as a faculty member you probably should explore this a bit. Most respondents felt it was important to explore the perceptions of both involved parties. Drs. Walsh, Rogers, Thoma and Chan all noted that it is imperative to listen to what the resident (Sean Peters) had to say about the situation. Dr. Rogers wisely noted that “…sometimes patients “split” the providers and give different stories” while Dr. Thoma stated that until the resident has had an opportunity to explain any explanations will be as flawed as the assumptions they rest on.

As an outpatient geriatrician, Dr. Michelle Gibson raises a point that there may be some inherent cultural biases that may occur that lead to scenarios like this one. She notes the response the resident, Dr. Peters, displays may be a symptom of a bigger underlying problem with the ‘hidden curriculum’ (i.e. he may act a certain way because he have seen others act a certain way around patients who did not turn out to have a “legitimate” injury, etc..)

2. Provide the opportunity to reflect back… it may provide you a window into their world

Most respondents brought up that as an educator you should ask the resident what his perceptions of the interaction were.  Listening to the resident’s perception of the situation will give you great insight into how best to approach the issue; if he shows insight, then you can discuss and debrief the ‘root causes’ of the professionalism transgression.

Some suggested contributing factors to this breach of professionalism were:

  • Compassion fatigue
  • Depression
  • Substance Abuse
  • Counter-transference
  • “Attribution error”
  • Personality Conflict
  • Problems outside the workplace (i.e. relationship issues)

3. Don’t shy away from the feedback

Every mistake or problem in training gives us the chance to feedback and improve, so many respondents felt that this provided us a unique opportunity to provide constructive guidance and feedback to the resident (Dr. Peters), but more importantly, it allows him to encounter this problem now as a trainee. As Dr. Nadim Lalani notes: “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.”

Feedback is important and, as Allan McDougall (a social science researcher) highlights, is often highly shaded by our “culture of training”.  He describes the work of Watling et al. (1), which he felt was relevant to this issue around providing feedback:

“…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).”

When compared to other disciplines (e.g. education and medicine), the value of feedback can be highly susceptible to cultural nuances – and Allan goes on to warn us about paying attention to our own local cultural nuances.

More broadly, Dr. Rob Rogers made a bold but important statement:

“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.”

4. Remember the patient

In clinical teaching, patient care is paramount.  Many respondents suggested that it is very important to have Dr. Peters apologize for the situation. As such, several esteemed respondents reminded us that it is important to arrange for Dr. Peters to apologize to the patient. Of course, this would necessitate that Dr. Peters agrees (or at least accepts) the patient’s version of proceedings.  In any event, empathizing with the patient is important – and this may be an opportunity for you to role model how to deal with this type of situation.

Dr. Michelle Gibson writes about her approach to this:

“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.

As we do not have the opportunity as Dr. Gibson has to discuss encounters again later with most of our patients, it is important to act in a timely manner during that visit.

Reference

1.  Watling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L. Beyond individualism: professional culture and its influence on feedback. Med Educ. 2013 Jun;47(6):585-94.

Case and Responses for Download

Click Here (or on the picture below) to download the case and responses as a PDF.

medic document

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan