Skip to content

MEdIC Series: The Case of the Fibbing First Year

2017-01-20T12:30:40+00:00

Welcome to season 3, episode 7 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, John Eicken, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss difficult medical education cases each month. As usual, the community discussion will be reviewed using qualitative research methods to produce a curated summary that will be combined with two expert responses to create a functional teaching resource.

This month’s case dives into the truth omitting or fibbing resident. Why do some learners lie and how should staff respond?

MEdIC Series: The Concept

MEdIC: The Case of the Fibbing First Year

by Dr. Teresa Chan

Caroline was struggling with one of her residents. As an assistant professor, her job included reviewing daily shift encounter cards for all of the off-service residents. Brian was an off-service resident who had been very keen to learn. He had, however, demonstrated significant knowledge deficits and multiple preceptors had expressed concern that he was not performing on par with his cohort. Caroline had met with Brian a few weeks ago to discuss her concerns, and they had created a tentative plan for remediation.

Fortunately, since their discussion Brian was reading more regularly, his attendance at teaching rounds was perfect, and his feedback from attendings was improving.  However, Caroline still had the impression that there was something ‘off’.

Dr. Caroline?” Brian approached Caroline timidly.

Yep. Gimme a second...” Caroline said as she intently stared at her computer screen and waved Brian to sit down. She was typing down some final notes on the resuscitation they had just managed.

No problem,” replied Brian, taking a seat.

I just wanted to present the patient with chest pain that we were chatting about when the patient in cardiac arrest came in. He’s been waiting a long time, and he’s getting agitated.

Caroline saved her progress on the note, and turned her attention to Brian. “Okay, tell me about your patient.

Brian began telling her the story of Gerry. Gerry was a 56-year-old gentleman who had come in with retrosternal chest pain that had resolved a few hours ago. Brian explained that he had no cardiac risk factors, no personal history of coronary artery disease, and was a thin, fit-looking guy. His physical exam had been “non-contributory”.

“Has he ever used cocaine or other drugs?” probed Caroline.

“Ummm…no…no. I don’t believe so?” stuttered Brian.

“You don’t believe so? Did you ask him?”

“Well, no, I didn’t ask him… not directly… I kinda asked him about his social habits –you know smoking, drinking, cannabis– so I’m certain that if he had a problem with drugs he would have told me, right? Plus he looks like a pretty clean-cut guy. He is a banker after all…”

Caroline suppressed a sigh. She had repeatedly impressed upon Brian the importance of explicitly asking about social habits, including recreational drugs. “Alright, well, we can ask again when we see him together. Tell me, Brian, what’s your differential for Gerry’s chest pain?” she pushed.

“Well, my differential is the typical things: ACS, PE, pneumonia, aortic dissection.”

“When you examined Gerry, did you find a pulse differential?”

“Um…. no?”

“You don’t sound sure, Brian.”

“No.”

“Did you do bilateral blood pressures on him?”

“Well, no…”

“Did you ask if the chest pain was maximal at onset, radiating to the back, or ripping and tearing in quality?”

“I asked him how bad the pain was and he said it was really severe so I think it was maximal at onset.”

“If you did not perform a thorough physical exam or ask important questions about the type of chest pain he was experiencing then how do you know aortic dissection is part of your differential?” Caroline’s frustration was starting to show. She took a deep breath.

“What about risk stratification for the other items in your differential?”

“What do you mean?”

“What’s his risk of PE? ACS? You remember all the decision rule scores that we’ve talked about, like the HEART score for ACS or the Well’s score for PE?”

“Well, he is PERC negative so I didn’t do the Well’s score.”

“But he’s over 50 years of age, right?  So he isn’t PERC negative.”

“Oh. Yeah. Sorry. So, I guess his Well’s score is 0.”

“You guess? Did you calculate it?”

Caroline was exasperated. She and Brian had discussed the PE and ACS risk stratification rules in depth during their most recent shift together. She had also suggested multiple resources for him to review and had emphasized the importance of obtaining a detailed history.

Brian seemed to still be deciding how he should answer Caroline’s question.

I don’t want you to lie to me” Caroline prompted, trying to remain calm.

Um…I’m not really lying; I just haven’t done the calculation…

Then that is what you should say rather than guessing.  Maybe you should stop for a moment, and think before your present a case” Caroline said with a note of anger creeping into her voice. Seeing Brian’s defeated expression, Caroline immediately regretted her harsh words. Forcing a smile, she suggested he go back and try to clarify the history.

Okay…” Brian mumbled, walking back towards Gerry’s room.


Discussion Questions

  1. Why do learners sometimes “fib” when presenting cases?
  2. Do you think it is difficult for Brian to admit that he is having difficulties? Why do you think that’s the case?
  3. Are there things that Caroline has done that may have potentiated his reluctance to ask for help?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses. We have decided to extend the discussion period to 2 weeks after the case is published. This time the 3 experts are:

  • Alex Sheng, MD is an assistant program director at Boston Medical Program Director. He is interested in graduate education and imaging utilization in the emergency department.
  • Dimitrios Papanagnou, MD, MPH, EdD(c) is the Vice Chair for Education in the Department of Emergency Medicine and the Assistant Dean, Faculty Development at the Sidney Kimmel Medical College associated with Thomas Jefferson University.
  • Andrew Eyre, MD is a current Brigham and Women’s emergency medicine fellow in medical education and simulation.

On May 7, 2016 we will post the expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

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.

Eve Purdy, BHSc MD

Eve Purdy, BHSc MD

Queen's University in Kingston, Ontario, Canada
Student editor at BoringEM.org
Founder of manuetcorde.org
Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • Kirsty Challen

    Interesting that you post this case so soon after the “pimping” discussion. Cause and effect maybe?

    I can certainly recall using “not as far as I know” as an answer when presenting and being asked a question that made me feel stupid or inadequate for not having asked the patient. (Then making sure I did go and check with the patient!). From the way this is written Brian is already having issues with confidence – he approaches “timidly”, he “stutters” his answers; sounds to me as though he needs some positive reinforcement of what he HAS done well before being led towards things he could improve. As someone who was previously labelled as officially “in difficulty” I can say that having all your seniors assume you are stupid/incompetent/dangerous rapidly results in being so terrified you can barely remember your own name.

    Off on a tangent, as a fan of EBM I find Caroline’s approach to the “thorough physical exam” and “important questions” interesting. I spend significant amounts of my time trying to explain to my residents and the GIM residents that we refer to that “typical cardiac pain” and the various “clinical features” of aortic dissection are poor at both ruling in and ruling out the diagnoses. Should we be castigating our trainees for failing to do parts of the “classic examination” that don’t actually contribute? Just a thought.

    • @kirstychallen:disqus – thanks for making the connection!! Yes, I think that the pimping described in the last case can be very much lead to a scenario like the one depicted above. The learning culture we (un)intentionally create in our clinical environments may result in various reactions… and ‘fibbing’ can be a result of a culture that values answers too much!

      In the age of EBM, I think your points are well-taken… I find myself quite a nihilist when it comes to physical exam now having read the JAMA Rational Clinical Exam series… :S

  • Kory London

    So I think Caroline actually carries a large amount of fault in this case. Yes, Brian appears to be a troubled learner, but they need support more than any others. What’s the point, when you know he is having a lot of difficulties in trying to crush him further?

    “You don’t believe so? Did you ask him?”

    “You don’t sound sure, Brian.”

    These are rhetorical questions that only serve to wound the learner further. We have moved forward in MedED to realize, at least for this generation of learners, that this form of patriarchal shaming doesn’t help, at least and especially those in need of remediation. Taking a tact of showing the learners how you reach conclusions, running the PERC rule in front of them (I usually open it in MDCalc) or talking about cases in which you find unexpected substance abuse (my favorite are the sweet elderly patients who occasionally use cocaine or were prior IVDUs) allows them to feel as though the situtation isn’t so highly charged.

    I also entirely agree with Kirsty about the utility of some historical and PE features. It’s still important to teach, but I usually discuss risk stratification in chest pain, say it’s vitally important as a physician to take risk factors into consideration but never rule something out due to a lack of them.

    The most important thing as faculty we need to do, other than to assure quality care for our patients, is to provide a hospitable learning environment for our students and residents. It’s easy to be frustrated with those with troubles, but letting that frustration get the best of you causes stuff like delaying presentations, as I assume the case is implying or shutting the faculty member out entirely. Difficult learners are those that we can have the greatest influence with. It takes a lot of patience, but they and the patients they eventually serve, deserve it.

    • Hi Kory:
      Thanks for your great response. I love your idea around patience… Do you think that is an innate trait of certain superstar educators? Or do you think this can be taught?

  • Cathy Grossman

    Tough situation on both sides – wonder what the exact remediation plan had been for the learner. Brian has some skin in the game here – ne should be held accountable for his actions, he should also be hopefully able to say ” i don’t know or I didn’t ask” when appropriate – but I wonder if an advocacy inquiry question ( with stated viewpoint of the questioner included) here would have opened up the discussion – to find out the reasons behind his behaviors. I’ll try to channel Jenny Rudolph as best that I can…”I noticed that you haven’t completed a full social history pertinent to this patient with chest pain. knowing if the patient has any Illicit drug use is important to steer your differential and may ultimately alter your medical therapy. It concerns me that at your level of training and after input from our prior conversations that you did not complete this task with proper thoroughness. What are you thoughts? ”

    However, Caroline certainly did the learner no favors with her learning climate.

    • Hi Cathy: Thanks for sharing your thoughts… Advocacy Inquiry approach is from… the simulation literature correct?

      • Cathy Grossman

        Yes – from the simulation literature. No way to know the reasons behind the learners actions without asking the learner somehow. Use some sort of open ended question at the end of this questioning to open up the discussion – never sure what you lob out the open ended question. You have to be prepared to spend some time on the answer however and having a discussion if you start down this pathway.

        Here’s a very pared down example “I saw (advocacy – first person observation about what you observed – stick to the facts of what you saw), I think (insert good judgement here – I am pleased/concerned/worried about this because ___) , I’m curious about (inquiry to find the reasons behind the learners frame)….” This is to simplistic but a start to how to think about this type of debriefing.

        Link to the Jenny Rudolph article describing this method.
        http://www.ncbi.nlm.nih.gov/pubmed/17574196

  • Nicolas Pineda

    As I was reading this case, it made a lot of sense to me as I have very little patience, and that is my disclosure: I need badly to work on this! 🙁
    I realised that probably Caroline’s attitude is not helping Brian at all. She has good intentions, because she recognise that this resident has problems, but at the same time, he is very keen to learn and he is making some progress. For some reason, at some point during the case presentation she loses it and she start being mean and not helpful at all with Brian (been there so many times…). In that scenario, the resident begins to shut down and the natural response to attacks is trying to defend him/herself. There is when fibbing appears! Residents feel so pressured to say what they think we want to hear, that sometimes they lie in order to get out of there as soon as possible!
    Ethics aside, my biggest problem with fibbing is that residents, most of the time have no idea how much they can hurt a patient doing this! They are residents, they are in training and of course no one knows everything, but specially residents, have no idea that they could be lying on something very important. In a patient with diarrhoea it is very important to know if he/she had traveled out of the country in the last 30 days. Should a resident know this? Yes. All residents know this? Probably not 100% of them. So if a resident is struggling presenting you this case, and if you ask him/her this question and he/she didn’t ask, most likely he/she is going to say no (that would be the default answer). Unless you see the patient again and ask yourself that question, you might get your patient in trouble. My point here is that of course lying is bad, but it can be worse when you have no idea on how important it is the issue you are lying about!
    I can’t say I never ever did that as a resident, but I remember that I went back to the patient and actually ask the question! Sometimes I had to go back and tell my attending something like: “well, I asked him again, and actually he was in Brazil 3 weeks ago…”
    I totally understand that residents might not learn this way and I have read and learn some of the theory behind avoiding these situations to happen, like setting a safe learning environment, watching you non verbal language, don’t be all negative and trying to find and say something positive before the negative, trying to understand the other, trying to critique actions not persons… but it is hard sometimes! Does anyone have this problem and some tips on how to do it? Are there some converted Carolines out there with helpful advices?
    As a final comment on what Kirsty and Theresa said about physical exam; PE really isn’t helpful at all MOST of the time! But you have the “curse of specificity”, meaning that most of the time you won’t find anything, but what if the patient actually haves asymmetrical pulses? The LR(+) of that finding for acute aortic dissection is really high and you should know it! So if it is present, it forces you to rule out the diagnosis, even if its present only in 15% or so of the AAD. If its there, you should do something about it, and in order to see if its there, you need to actively seek for it! Remember patients don’t care about number or probabilities, for them, they are their 100%.

    • Hi Nico: Thanks for your comments – I do think that you are right, there are times that Physical Exam can be helpful… I joke about being a nihilist, but in certain cases everything seems to just be there… your point is well taken. How do you keep your participants from being discouraged?

  • Michael

    Context is interesting. Brian has seen the patient, and then been pulled into an arrest (was this straightforward or unusually stressful? Is it impacting on both of their behaviours?) He’s now aware his patient is getting agitated – so has presumably been back to review him. I can easily envisage a scenario where he has asked many of these questions and thought about the risk stratification, but then been distracted by the arrest and pressured into presenting without time to pull his thoughts together again and therefore come across as having done a poor assessment. Of course, it could also have been a weak assessment initially – and the approach to the two scenarios should probably be different.

    His approach to her is ‘timid’ – does that reflect his personality, his preparation for this case, or his previous interactions with Caroline? She appears to get quite aggressive fairly easily in the conversation – again, if this is because they’ve had a similar conversation many times before it may be understandable (if not the best way of dealing with the situation); if it’s the second conversation about chest pain risk scores it comes across as more disproportionate. She may have spent some time talking about PE and ACS tools recently, but how many other conditions, criteria, scores, etc have been mentioned by other colleagues in the same period of time?

    Someone who is keen to learn, attending teaching consistently, and appears receptive to feedback seems at odds with the portrayal now of someone consistently making the same mistakes. It would be interesting to see if other seniors had the same experience of him.

    If he’s having difficulties with this particular senior, it would be very hard for him to discuss this with said senior. Maybe Caroline could consider asking a colleague to speak with him – either taking over a supervisory role, or as a one-off, to consider this possibility.

    • John Eicken

      Michael – thanks for your sharing your thoughts. I think your point about Brian’s presentation possibly being affected by the resuscitation that just occurred on a different patient is a great thought. I do think there are times when providers’ reactions differ in response to events occurring in the emergency department, particularly junior residents who do not possess the same depth of experience as the more senior providers. What are your thoughts on how Caroline could have effectively explored this possibility with Brian?

      • Michael

        Step one I think is always to recognise the possibility – in ourselves and our trainees. Some cases are easier to spot as having the potential to upset people – anything in children for instance – but almost any case can resonate with an individual for a whole range of reasons. Giving people an opening to express this can help – looking out for subtle cues in language or facial expression and asking specifically, or making a habit of asking a general question (even as simple as “are you ok?” with eye contact) after a resus, significant diagnosis or interaction, medical error, etc. There was some discussion around this on a previous MEdIC case (https://www.aliem.com/2014/medic-series-case-debriefing-debacle-expert-review-curated-commentary/)

        Unfortunately Brian and Caroline now seem to be past this point. He’s now in the position where stating he doesn’t know will lead to further criticism (possibly justified, possibly not), while confabulation is unprofessional, could potentially harm the patient, and given that he’s not making a consistent effort to hide it, also leads to criticism. During a stressful day, in a speciality that isn’t there own (assuming I understand off-service correctly – it’s not usual terminology in the UK) I can understand the temptation to ‘fib’ based on what you believe the answer to be to try to avoid one more stress. It’s also conceivable that some ‘fibs’ from learners are unconscious; we know memory is not infallible (some discussion here as a random example http://www.visualexpert.com/Resources/eyewitnessmemory.html), and people will not always be able to differentiate between something they were told, and the way in which they interpreted it – they will recall both as facts presented by the patient.

        At this stage in the case, the discussion isn’t abstract or general – it is about an individual patient (who is already agitated at the wait). Someone needs to break the impasse to make the right decision for the patient – Brian could do it (“I’m sorry but I forgot some of those rules; can we review them and I’ll go back to the patient/can we review him together?”) but given the power dynamic it’s going to be easier for Caroline (“Let’s go over the criteria for Wells and the HEART score now then go to see the patient and decide what we need to do next.”)

        If this episode raises further concerns about his progress and performance, I think this is better addressed later when there is time and space for a proper exploration of what has happened, his insight, etc. I suspect this will be more productive the following day, when Caroline is less annoyed and Brian less defensive.

        I appear to have drifted somewhat from the posed questions – but hopefully not too far away from the topic at hand.

  • Sara Krzyzaniak

    I agree with previous comments, and don’t want to rehash what was previously said. I will add/reinforce what Kristy said: struggling residents are keenly aware of their struggle and make every attempt to “prove” competence. My most confident residents are the ones who freely admit they didn’t do something. Creating a culture of “safety in not knowing” is important. As others have said, Caroline could have improved the climate of their interaction. This is a great time for bedside teaching. Go to the bedside and ask the questions he didn’t ask (maybe he’s not sure how to broach the subject of cocaine), or get manual BP’s (nurses aren’t the only ones who can check BP!). Make the learning a team sport, rather than give the learner a list of items to check off and report back on.