Holly J. Humphrey

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Background: The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or “sign-out”. This study aims to describe how communication failures during this process can lead to patient harm. Methods: In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers. Results: Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (κ 0.78–1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems. Conclusion: Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

A theoretical framework and competency-based approach to improving handoffs

Background: Once characterised by remarkable continuity of care by a familiar doctor, patient care today is delivered by multiple physicians with varying degrees of knowledge of the patient. Yet, few trainees learn the potential risks of these transitions and the strategies to improve patient care during handoffs. Little is known regarding the mechanisms by which handoffs affect patient care. Results: Building on theoretical constructs from the social sciences and illustrated with a case study of the implementation of a night float service for the inpatient general medicine services at the University of Chicago, a conceptual framework is proposed to describe how handoffs affect both patients and physicians. Conclusion: Using this conceptual framework, recommendations are made for formal education based on the core competencies of communication and professionalism. Opportunities to educate trainees in acquiring these skills are described in the context of handoffs of patient care.

Association of Workload of On-Call Medical Interns With On-Call Sleep Duration, Shift Duration, and Participation in Educational Activities

CONTEXT Further restrictions in resident duty hours are being considered, and it is important to understand the association between workload, sleep loss, shift duration, and the educational time of on-call medical interns. OBJECTIVE To assess whether increased on-call intern workload, as measured by the number of new admissions on-call and the number of previously admitted patients remaining on the service, was associated with reductions in on-call sleep, increased total shift duration, and lower likelihood of participation in educational activities. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of medical interns at a single US academic medical center from July 1, 2003, through June 24, 2005. Of the 81 interns, 56 participated (69%), for a total of 165 general medicine inpatient months resulting in 1100 call nights. MAIN OUTCOME MEASURES On-call sleep duration, estimated by wrist watch actigraphy; total shift duration, measured from paging logs; and participation in educational activities (didactic lectures or bedside teaching), measured by experience sampling method via a personal digital assistant. RESULTS Mean (SD) sleep duration on-call was 2.8 (1.5) hours and mean (SD) shift duration was 29.9 (1.7) hours. Interns reported spending 11% of their time in educational activities. Early in the academic year (July to October), each new on-call admission was associated with less sleep (-10.5 minutes [95% confidence interval {CI}, -16.8 to -4.2 minutes]; P < .001) and a longer shift duration (13.2 minutes [95% CI, 3.2-23.3 minutes]; P = .01). A higher number of previously admitted patients remaining on the service was associated with a lower odds of participation in educational activities (odds ratio, 0.82 [95% CI, 0.70-0.96]; P = .01]. Call nights during the week and early in the academic year were associated with the most sleep loss and longest shift durations. CONCLUSION In this study population, increased on-call workload was associated with more sleep loss, longer shift duration, and a lower likelihood of participation in educational activities.

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study

Background: Little is known regarding how internal medicine residents manage uncertainty during decision making and subsequent effects on patient care. The aims of this study were to describe types of uncertainty faced by residents, strategies employed to manage uncertainty and effects on patient care. Methods: Using critical incident technique, residents were asked to recall important clinical decisions during a recent call night, with probes to identify decisions made during uncertainty. They were also asked to report who they approached for advice. Three authors independently coded transcripts using the constant comparative method. Results: The 42/50 (84%) interviewed residents reported 18 discrete critical incidents. Six categories emerged and mapped to the domains of the Beresford Model of Clinical Uncertainty: technical uncertainty (procedural skills, knowledge of indications); conceptual uncertainty (care transitions, diagnostic decision making and management conflict) and personal uncertainty (goals of care). In managing uncertainty, residents report a “hierarchy of assistance”, using colleagues and literature for initial management, followed by senior residents, specialty fellows and, finally, the attending physician. Barriers to seeking the attending physician’s input included the existence of a defined hierarchy for assistance and fears of losing autonomy, revealing knowledge gaps, and “being a bother”. For 12 of the 18 cases reported, patient care was compromised: delay in procedure or escalation of care (n = 8); procedural complications (n = 2); and cardiac arrest (n = 2). Conclusion: Resident uncertainty results in delays of indicated care and, in some cases, patient harm. Despite the presence of a supervisory figure, residents adhere to a hierarchy when seeking advice in clinical matters.

Third-year medical students' participation in and perceptions of unprofessional behaviors.

Background Students’ perceptions of and participation in unprofessional behaviors may change during clinical clerkships. Method Third-year students anonymously reported observation, participation, and perceptions of 27 unprofessional behaviors before and five months after clerkships. Results Student observation (21 of 27) and participation (17 of 27) in unprofessional behaviors increased (P < .05). Students perceived unprofessional behaviors as increasingly appropriate (P < .05 for six behaviors). Participation in unprofessional behaviors was associated with diminished likelihood of perceiving a behavior as unprofessional (P < .05 for nine behaviors). Conclusions Student observation and participation in unprofessional behaviors increased during clerkships. Participation in unprofessional behaviors is associated with perceiving these behaviors as acceptable.

Alcohol and Other Substance Abuse and Impairment among Physicians in Residency Training

Substance abuse and impairment are serious societal problems. Physicians have historically had high rates of substance abuse, which has been viewed as an occupational hazard. Most authorities agree that the rate of alcoholism among practicing physicians is similar to that among control populations and that the rates of other substance abuse are greater, although some studies have shown no difference. Data about substance abuse among residents in training are limited but suggest that the use of benzodiazopines is greater than that among age-matched peers, whereas the use of alcohol is similar between the two groups. Medical institutions, including those with teaching programs, have legal and ethical responsibilities concerning substance abuse among current and future physicians. Many training programs, however, do not provide educational programs on this subject, do not have faculty trained in substance abuse medicine, and do not have a formal system to address the problem of residents who are suspected or known to be substance abusers. This position paper examines the extent of substance abuse, including alcohol abuse, among physicians in residency training. It outlines approaches to the problem and delineates responsibilities of institutions and residency program directors. Recommendations are made to establish an informational program and a clearly defined, organized process to address the problems of substance abuse among residents. Careful and humane approaches can be used to identify and treat residents with substance abuse problems and thus allowing them to complete their training as competent and drug-free professionals.

On-call supervision and resident autonomy: from micromanager to absentee attending.

D T M i y f t n 1984, Libby Zion, an 18-year-old woman, died in New York hospital of what was determined to be an dverse drug reaction; the grand jury investigating er death found contributing causes to be resident xhaustion and inadequate supervision. Although the esulting media spotlight focused on duty hour reglations, little attention has been paid to formalizing r regulating supervision provided to physicians-inraining. Despite subsequent revision of the New ork State health code mandating reduced work ours and increased clinical supervision, little effect as been observed in the amount and quality of esident supervision, especially in the overnight peiod when residents are often admitting new atients. In addition to preventing resident fatigue, providng adequate supervision is a fundamental aspect of nsuring safe patient care in teaching hospitals. Atending physicians in a supervisory capacity may be eld accountable for patient outcomes; an on-call apacity may be sufficient to establish a patient– hysician relationship and duty to supervise. Given hat they employ physicians-in-training for clinical are, sponsoring hospitals may be held vicariously iable for adverse outcomes caused by residents actng in accordance with their job description. As a esult of the duty hour regulations, many programs

Residents' perceptions over time of pharmaceutical industry interactions and gifts and the effect of an educational intervention.

Purpose To describe change in residents’ attitudes toward gifts from and interactions with industry and to measure the effects of a formal educational workshop on changes in perceptions. Method At the University of Chicago, 118 internal medicine residents completed an observational survey and took part in a controlled intervention across three years (2001–2004) of residency. Four cohorts of residents completing the program in 2004–2007 participated. The intervention was an interactive educational workshop, including reviews of literature and guidelines, and three videos demonstrating routine resident interactions with pharmaceutical representatives. Residents graduating in 2005 were the intervention group and residents graduating in 2004 the comparison group. Analysis of variance and linear regression models were used to determine the relationship between variables. Results Residents perceived “lunch sponsored at noon conference” and “pharmaceutical representative brief talk at noon conference” as increasingly appropriate over their training period (p < .02). Residents perceived “pens, notepads, pocket antibiotic guides” as increasingly appropriate and “tickets to sporting events,” “round of golf,” and “travel/registration for national conference” as increasingly inappropriate (p < .05). The intervention group was more likely to rate only one item, “lunch at noon conference,” as less appropriate (p = .042). Conclusions Residents’ perceptions toward industry gifts and interactions changed modestly during their training to reflect institutional policy. “Appropriate” gifts of minimal value were generally perceived as increasingly appropriate, whereas “inappropriate” gifts were perceived as increasingly inappropriate over time. An educational workshop alone may not significantly alter residents’ perceptions toward industry without the implementation of broad and consistent institutional policy.

No time for teaching? Inpatient attending physicians' workload and teaching before and after the implementation of the 2003 duty hours regulations.

Purpose Understanding the association between attending physicians’ workload and teaching is critical to preserving residents’ learning experience. The authors tested the association between attending physicians’ self-reported workload and perceptions of time for teaching before and after the 2003 resident duty hours regulations. Method From 2001 to 2008, the authors surveyed all inpatient general medicine attending physicians at a teaching hospital. To measure workload, they used a conceptual framework to create a composite score from six domains (mental demand, physical demand, temporal demand, effort, performance, frustration). They measured time for teaching using (1) open-ended responses to hours per week spent doing didactic teaching and (2) responses (agree, strongly agree) to the statement “I had enough time for teaching.” They conducted multivariate logistic regression analyses, controlling for month, year, and clustering by attending physicians, to test the association between workload scores and time for teaching. Results Of 738 eligible attending physicians, 482 (65%) completed surveys. Respondents spent a median of three hours per week dedicated to teaching. Less than half (198; 43%) reporting enough time for teaching. The composite workload scores were normally distributed (median score of 15) and demonstrated a weak positive correlation with actual patient volume (r = 0.25). The odds of an attending physician reporting enough time for teaching declined by 21% for each point increase in composite workload score (odds ratio = 0.79 [95% confidence interval 0.69–0.91]; P = .001). Conclusions The authors found that attending physicians’ greater self-perceived workload was associated with decreased time for teaching.

Professionalism in the Era of Duty Hours: Time for a Shift Change?

CONCERNS HAVE BEEN RAISED THAT THE IMPLEMENtation of shorter duty hours for residents may erode the professional allegiance of these physicians to their patients. Those who trained before duty hour regulations often dismiss current physicians in training as lifestyle oriented and not committed to the profession. Even residents who completed their internship training before 2011 have become instant “grandfathers,” sharing in these sentiments. Yet old values do not simply die in a new system. Despite duty hour restrictions, today’s trainees continue to exhibit behaviors consistent with “nostalgic professionalism,” defined as consistently placing a patient’s or the profession’s needs above one’s own personal needs. However, at times these behaviors directly conflict with the current system of medical training. This creates a challenge for medical educators: how can the conflict between nostalgic definitions of professionalism and the new model of medical training be reconciled? Answering this question requires a deeper understanding of specific circumstances in modern residency training in which resident actions consistent with nostalgic professionalism conflict with mandated regulation.