Jennifer A. Best

‘Speaking up’ about patient safety concerns and unprofessional behaviour among residents: validation of two scales

Objective To develop and test the psychometric properties of two new survey scales aiming to measure the extent to which the clinical environment supports speaking up about (a) patient safety concerns and (b) unprofessional behaviour. Method Residents from six large US academic medical centres completed an anonymous, electronic survey containing questions regarding safety culture and speaking up about safety and professionalism concerns. Results Confirmatory factor analysis supported two separate, one-factor speaking up climates (SUCs) among residents; one focused on patient safety concerns (SUC-Safe scale) and the other focused on unprofessional behaviour (SUC-Prof scale). Both scales had good internal consistency (Cronbachs α>0.70) and were unique from validated safety and teamwork climate measures (r<0.85 for all correlations), a measure of discriminant validity. The SUC-Safe and SUC-Prof scales were associated with participants’ self-reported speaking up behaviour about safety and professionalism concerns (r=0.21, p<0.001 and r=0.22, p<0.001, respectively), a measure of concurrent validity, while teamwork and safety climate scales were not. Conclusions We created and provided evidence for the reliability and validity of two measures (SUC-Safe and SUC-Prof scales) associated with self-reported speaking up behaviour among residents. These two scales may fill an existing gap in residency and safety culture assessments by measuring the openness of communication about safety and professionalism concerns, two important aspects of safety culture that are under-represented in existing metrics.

Is There a Doctor in the House

Is There a Doctor in the House? THE FIRST TIME MY SON HAD A SEIZURE, HE WAS 8 months old, and I was an unmitigated disaster. My husband, who has no medical training, stepped calmly through the ABCs as I hyperventilated, ran circles around him in the dark, and dialed 991—twice. By the time the ambulance arrived, my son’s shaking had long since stopped, yet it’s safe to say mine continued unabated. Despite my own training in patient assessment, I clung to every bit of reassurance offered by the paramedics. They spoke deliberately and calmly in layperson’s terms, yet I remembered very little of what was said. Our son was transported to the hospital and admitted overnight for observation. A pediatric neurologist reassured us that this seizure, in the setting of a fever, did not necessarily predict the development of epilepsy and discharged us home to familiar surroundings, but I was unsettled. Without warning, the world as I knew it had changed. In retrospect, I was stunned and embarrassed by my loss of composure. As a hospitalist who routinely manages acute changes in clinical status, I felt awful that I had forgotten to check first to see if my baby was breathing. I am not a pediatrician, but I felt I should have remembered that febrile seizures are common in childhood. The day that fact was first related to me remains clear in my mind. I am certain that I attended the neurology lecture on my pediatrics rotation; I even recall that chicken was served. Sadly, that’s where my recollection ends. Additional details have long since been supplanted by internal medicine training. The surprising revelation that night was not my lack of pediatric knowledge, but rather the manner in which my heart rendered my mind useless in a situation where it was otherwise tuned to excel. This paradox gave way to parental angst and self-doubt. A month after the initial event, my son had a longer seizure in the absence of fever. He and I had been playing and laughing together on the floor. His sudden silence gave rise to a cold, growing fear fully realized with the onset of convulsions. I clutched him to my chest and moved with him toward the telephone, willing my legs with each step to bear my weight. I called 911 (correctly the first time) and we endured another long, anxious night in the emergency department. I disclosed my occupation only when the neurology resident said I looked familiar. Perhaps driven by a collegial desire to be thorough, he expounded on the relationship between epilepsy and sudden death but offered no additional intervention. “Just call the clinic if it happens again,” he concluded, as my heart sank to my feet. “We don’t need to see him every time.” But the next time, the seizing didn’t stop. Helplessly, my husband and I sheltered our son’s little body with our own as an intravenous line was placed and medications were given. I held him as he was sedated for his MRI, fighting back tears as his body went limp. As I reluctantly handed him to the anesthesiologist, a curtain was quickly whisked between me and the medical team as if to underscore that this world was fundamentally different from the one in which I functioned comfortably on a daily basis. Early the next morning, from a strange existential distance, I watched the neurology team round at our bedside. As an attending at a teaching hospital, I would have been on their side of the bed on any other day. I recognized the comfortable and familiar banter between the detailoriented intern and the senior resident eager to prove his mettle, but their presence did nothing to assuage my anxiety. My husband and I were not included in the conversation, and no reassurance was offered. That same afternoon, I asked the intern if I could read the daily progress note. “Not without a doctor present,” she countered. I did not offer that I am a physician, concerned she may sense that I was seeking special treatment. Being a physician had little to do with me at that moment. My education provided no comfort and, on the contrary, alerted me to alarming possibilities I was not prepared to consider. After a three-day stay, we left with prescriptions for daily zonisamide and diazepam for refractory seizures. I never saw the consultation note. Although I doubt that my emotional response to my child’s illness is unique as parenthood goes, certain situations have caused me to consider whether my encounters with the medical system as a physician-parent deviate from common experience. During one of his many seizures, our son was ill with croup and turned unmistakably blue. Well rehearsed in the process by now, I called 911 immediately, unwilling to risk respiratory arrest while waiting for diazepam to take effect. One of the paramedics, upon learning that I am a physician, chastised me for calling them prior to its administration. His manner was condescending and I felt sheepish, yet watching the ragged breathing of my pale and lethargic son, I felt my decision was justifiable. Is it reasonable to think that a physician should have a higher threshold for seeking medical attention? To the contrary, I felt that to expect of me a greater tolerance for the suffering of my own child was to demand the impossible. The paramedic’s reprimand, I felt, was unfair.

Improving Resident Engagement in Quality Improvement and Patient Safety Initiatives at the Bedside The Advocate for Clinical Education (ACE)

Quality improvement (QI) and patient safety (PS) are essential competencies in residency training; however, the most effective means to engage physicians remains unclear. The authors surveyed all medicine and surgery physicians at their institution to describe QI/PS practices and concurrently implemented the Advocate for Clinical Education (ACE) program to determine if a physician-centered program in the context of educational structures and at the point of care improved performance. The ACE rounded with medicine and surgery teams and provided individual and team-level education and feedback targeting 4 domains: professionalism, infection control, interpreter use, and pain assessment. In a pilot, the ACE observed 2862 physician-patient interactions and 178 physicians. Self-reported compliance often was greater than the behaviors observed. Following ACE implementation, observed professionalism behaviors trended toward improvement; infection control also improved. Physicians were highly satisfied with the program. The ACE initiative is one coaching/feedback model for engaging residents in QI/PS that may warrant further study.

Spontaneous retroperitoneal hematoma originating at lumbar arteries in context of cirrhosis

A 56-year-old male presented to the emergency department with a 2-week history of increasing abdominal girth, nausea, vomiting, and lower extremity edema. His girlfriend had also noted a yellow tinge to his skin and eyes. His past medical history was significant for bipolar disorder, alcoholrelated seizures, and pneumonia. He had no allergies and denied medications prior to admission. Family history was negative for liver disease and social history was notable for ongoing tobacco use and alcohol dependence. He was afebrile with stable vital signs. Physical examination demonstrated an alert gentleman whose answers to questions required occasional factual correction by his partner. His abdomen was distended and nontender with prominent vasculature and shifting dullness. Lower extremity edema was symmetric and bilateral, rated as 2þ. Scattered spider angiomata and a fine bilateral hand tremor without asterixis were also noted. Initial laboratory data demonstrated a white blood cell count of 13,900/lL, hematocrit 37%, and platelet count 176,000/lL. His sodium was 130 mg/dL, blood urea nitrogen (BUN) 1 mg/dL, and creatinine 0.7 mg/ dL. International normalized ratio (INR) was 1.8, aspartate aminotransferase (AST) was 117 U/L, alanine aminotransferase (ALT) 33 U/L, alkaline phosphatase 191 U/L, total bilirubin 9.2 mg/dL, total protein 7.0 g/dL, and albumin 1.9 g/dL. Abdominal ultrasound revealed a diffusely hyperechoic liver with a large amount of ascites. The patient was admitted with the diagnoses of presumed alcoholic hepatitis and end-stage liver disease. Model for End-Stage Liver Disease (MELD) score was 21 and discriminant function 16.8. Paracentesis demonstrated a serum-ascites albumin gradient of >1.1 and no evidence of spontaneous bacterial peritonitis. Diuresis was initiated. He was placed on unfractionated heparin at a dose of 5000 units every 8 hours for deep venous thrombosis (DVT) prophylaxis. By hospital day 3, the patient’s laboratory values had improved, yet his stay was prolonged by alcohol withdrawal requiring benzodiazepines, altered mental status presumed secondary to hepatic encephalopathy, acute renal failure, aspiration pneumonia, and persistent unexplained leukocytosis. He required medical restraints during this time given confusion and propensity to ambulate without assistance, yet sustained no falls or other known trauma in care delivered during this time. Between days 14 and 17, the patient’s hematocrit fell from 36% to 30%; vital signs remained stable. He underwent an uncomplicated, ultrasound-guided therapeutic paracentesis, which yielded 1.4 L of straw-colored fluid on the afternoon of day 17; the procedure was attempted only on the right side. On the morning of day 18, the patient’s blood pressure dropped to 78/55 mmHg with a pulse of 123 beats per minute; he became pale and unresponsive. Physical examination was notable for somnolence and a tender, warm left flank mass, contralateral to his paracentesis site. No flank or periumbilical ecchymoses were identified. Complete blood count demonstrated a white blood count (WBC) of 22,970/lL, hematocrit 16%, and platelet count 104,000/lL. INR was 2.0, unchanged from the last check on day 10. Partial thromboplastin time was 41 seconds and fibrinogen was 293 mg/dL (normal 150-400 mg/dL). Peripheral blood smear was negative for red cell fragments. Blood chemistries revealed a sodium of 134 mg/dL, bicarbonate 20 mEq/L, anion gap 7, BUN 24 mg/dL, and creatinine 1.6 mg/dL (up from 1.0 mg/dL the previous day). His venous lactate level was 4.6 mmol/L and arterial blood gas sampling on room air demonstrated a pH of 7.35, partial pressure of carbon dioxide (pCO2) 29 mmHg, partial pressure of oxygen (pCO2) 54 mmHg, and bicarbonate 15 mEq/L. A femoral introducer was placed for volume resuscitation and the patient was urgently transfused with packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) to correct his coagulopathy. Computed tomography of the abdomen revealed a large left retroperitoneal hematoma measuring 15 15 22 cm (Figure 1). Despite transfusion, his hematocrit continued to fall. Urgent angiography was performed, upon which he was found to have active bleeding from the left L3-L5 lumbar arteries. These were successfully embolized. He required PRBCs and FFP transfusion only once following this procedure. Given a transient decrease in his urine output, his bladder pressures were followed closely for evidence of abdominal compartment syndrome, which did not develop. He was transferred from the intensive care unit (ICU) to the floor on day 20, where his physical exam and hematocrit remained stable and his delirium slowly cleared. He was ultimately discharged to a skilled nursing facility on day 33.

The Things We Have Lost

When most people consider the grief endured by physicians in training, they look first to the devastating narratives of patient care—sudden illness, agonizing decline, putrid decay, untimely death, haunting errors, and crushing uncertainty. Even more than a decade from residency, I am pierced by these tragic moments and faces— each still heart-shatteringly vivid. Recognizing the direct emotional toll of patient care, medical educators in some training programs have earmarked time for death rounds,1 Schwartz rounds,2 or narrative medicine3 sessions. Many of these interventions are deployed in highintensity settings within the clinical learning environment where residents wrestle daily with ethical dilemmas or end-of-life dynamics. Where physician well-being is concerned, I offer that these curricular endeavors are a natural starting point, but may not represent a complete solution. With distance from my own training and countless meetings with residents as mentor and advisor, I am less sure that these charged patient encounters underpin the burnout and depression epidemic in the graduate medical education community. Rather, my residents’ personal stories suggest that initiatives to improve physician wellness must address other forms of grief and loss that are no less inevitable, but less overt. We enter the field of medicine steeled to the fact that some of our patients will die. However, many of us may be less prepared for the reality that parts of ourselves will also die in the process. Although we may not recognize these sacrificial “deaths” as such in the moment, these losses are deeply visceral and their effects additive: • Forming close-knit clinical teams each month that disband without a proper acknowledgment or good-bye. • Being asked by family to provide medical advice for an ill relative and finding no space in that role for personal sadness or the intense anxiety of “impostor syndrome.” • A romantic relationship whose future success lies with the computerized Match algorithm. • Hoping to become pregnant with a “ticking clock” but ovulating while assigned to a week on a night rotation. Again. • Absence from “unique and unrepeatable” events— holidays, birthdays, weddings, and funerals. • Vigorous and repeated bedside challenges to one’s core ethical, moral, and spiritual framework. • Strain in longtime friendships related to years of sustained unavailability, compounded by geographic distance. • The sad recognition that months have passed since you’ve played your cello. • Lamenting deterioration in one’s physical body that has accumulated in the wake of sleep disturbance, quick meals, little exercise, and delayed health maintenance. Each anecdote is an intimate door to the heart— closed quietly, dutifully, and without fanfare. Each reflects a loss that transcends clinical rotation, duty hours, or patient population. In moments when I am allowed to truly see, I see longing in their eyes. Yet in light of life and death, hardly worth mentioning, right? Wrong. In a session on physician well-being at this year’s Accreditation Council for Graduate Medical Education conference, 50% of polled attendees had experienced at least one institutional suicide. One of the resident panelists shared the story of his medical school roommate who unexpectedly ended his life: “He believed he had been blessed,” he said, and as the story unfolded, I came to believe he had been. He had boasted a supportive family, innate talent, a close-knit social community, and the opportunity to train at an elite institution. Although some may say blessed, others fortunate, I believe that most of our trainees would say the same of themselves to varying degrees. Most are humbly aware that along the road of medical training, they have benefited from family support, financial assistance, mentorship of leaders within the medical community, and perhaps a measure of luck. In the face of escalating personal distress, they tell themselves, not inappropriately, that they are the privileged few. First-world problems, they say. Who am I to complain? They carry that sentiment from the preclinical years to the bedside, where they sit eye-to-eye with patients. With trembling hands and voices, they learn to break bad news and do so regularly, seemingly always to the nicest of people. They learn to hold space for families in despair and deal haltingly in uncertainty. They discharge chronically ill or addicted patients without homes to the street. Day after day, residents experience firsthand the arbitrary nature of life and death and exist within the thinness of the line between. They, as I once did, stand before the ravages of disease and think: It could be so much worse. And they are right—it could always be worse. Nowhere is this more palpably observed than in the practice of medicine. I read an ancient proverb that says, “I was unhappy about having no shoes until I met the man who had no feet.” But because of these stark and constant comparisons, heartbroken residents remain silent about their personal pain. And when on occasion one chooses death as the better way, the community is horribly saddened, vowing to do better: “How could we have known?” we say. “We didn’t know.” A PIECE OF MY MIND

Improvement Happens: an Interview with Furman McDonald, MD MPH

In October 2010, the Accreditation Council on Graduate Medical Education (ACGME) published a long-awaited modification to its 2003 common duty hour standards following an international symposium and intensive task-force review of recent literature on safety, supervision, sleep and competence. Although this recent duty hour policy stopped short of adopting all recommendations of the 2008 Institute of Medicine (IOM) report (“Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”), particularly the 5-h nap following 16 h of continuous duty, the new standards were strongly informed by the report, leaving many training programs scrambling to marshal resources and develop new systems to ensure compliance by the July 1, 2011 implementation deadline.