This education article Sim Healthcare is a head-to-head comparison between video laryngoscopy (VL) versus direct laryngoscopy (DL) in a difficult airway simulation model. In this prospective, convenience sample of EM attendings and residents who were all novice operators of VL, the subjects were asked intubate 3 types of mannequin scenarios using a Macintosh curve laryngoscope for DL and a Glidescope for VL.
I am constantly surprised by medical student and resident comments that they rarely receive feedback. In contrast, seemingly on every shift, I hear faculty giving little nuggets of feedback – during the oral presentation, during the resuscitation, after a difficult interaction, etc. There must be some disconnect.
This multi-institutional, survey-based, observational study at 17 EM residency programs asked attending physicians and residents about feedback in the ED. The primary outcome measure was overall satisfaction with feedback.
The response rate was 71% for attendings (373/525) and 60% for residents (356/596). Side note: Survey studies are generally inconclusive if response rates are
There was a statistically significant difference between the feedback satisfaction scores (on scale of 1-10 with 10 being highest satisfaction).
- Attending physicians: 5.97
- Resident physicians: 5.29
Furthermore, when evaluating the quality of different aspects of feedback delivery, there were statistically significant differences in the satisfaction ratings between the attendings and residents. Overall, attendings felt more satisfied with feedback delivery on various topics than residents were.
- Quality of positive feedback (50% attendings, 36% residents)
- ” of constructive feedback (29% attendings, 22% residents)
- ” of feedback re: procedural skills (48% attendings, 34% residents)
- ” of documentation (36% attendings, 28% residents)
- ” of ED flow management (29% attendings, 21% residents)
- ” of evidence-based decision making (28% attendings, 18% residents)
What is more interesting to me is the discrepancy between what the attendings and residents perceived in frequency of feedback. Specifically, 42% of attendings stated that feedback delivery was being done on every shift. Contrast this to only 7% of residents who felt the same. Why the disconnect? Is it purely misperception?
In re-reading this article, I wonder how this question was phrased though. Was it indeed perception or fact?
Let’s say there are usually 5 residents per attending shift, and the attending gives feedback every shift to at least 1 person. When surveyed, the attending would answer – “Yes, I give daily feedback”. In contrast, because there are multiple learners, residents may not have received daily feedback. By law of averages, residents would have received feedback every 5 shifts.
The data showing that 42% of attendings and 7% of residents were involved in feedback delivery every shift may actually be true (rather than pure perception). This illustrates the trickiness of designing and writing surveys.
We should be working to improve positive and constructive feedback delivery in the Emergency Department, despite the various obstacles.
Yarris L, et al. Attending and resident satisfaction with feedback in the emergency department. Acad Emerg Med. 2009; 16:S76–S8.
Also see previous post on Failing at Feedback in Medical Education.
It’s a busy day in the Emergency Department and there are 5 new patients to be seen. The waiting room is overflowing. As the attending, you are getting barraged with a million questions to answer and problems to fix.
There is also a case of a full-thickness burn patient going to the OR in the next few minutes. She’d be a perfect teaching case for the residents.
Should I have the residents go see the new patients, or should I pull them all aside to show them the physical findings and teach about burns for 5-10 minutes?
- Is non-judgmental
- Is non-threatening
- Is specific
- Consists of both positive and constructive elements
- Offers alternatives
Medicolegal woes often can be tracked back to poor documentation by the physician.
This article is a retrospective chart review of 384 EM resident charts, focusing on the documentation of the neurologic exam. Charts were selected if their chief complaints were neurologic or psychiatric in nature. A non-validated measurement tool for evaluating a neurologic exam was created based on discussions with attending emergency physicians. I have to agree with the chosen criteria. Documentation in each of the following criterion receives 1 point for a maximum score of 8.
Patient care versus education
This is the tug-of-war struggle that residency programs constantly grapple with. Residents work in an apprenticeship model where they are both patient providers and learners. Both are critical in residency training, but they sometimes negatively impact each other. For instance, EM residents hand-off their patients to covering residents while attending their weekly conference classes. In contrast, residents may skip that day’s board teaching rounds to manage an acutely decompensating patient.
This was the question addressed by the landmark 1910 Flexner Report from the Carnegie Foundation for the Advancement of Teaching. Back in the early 1900’s, residency training did not exist yet, and students entered clinical practice immediately after graduation from medical school. The quality of medical training varied significantly with alarming deficiencies in many medical schools. An independent, nonprofessional organization was commissioned to report about the situation in order to pressure the public to reform medical school education.