Nicholas J. Batley

The discrepancy rate between preliminary and official reports of emergency radiology studies: a performance indicator and quality improvement method

Background At teaching hospitals, radiology residents give preliminary reports for imaging studies requested from the Emergency Department (ED). Discrepancy rates between preliminary and final reports represent an important performance indicator. Purpose To present a system for feedback and follow-up of discrepancies, identify the variables associated with the rate and severity of such discrepancies, target the weaknesses, and suggest the need of a standard reference value for comparison among institutions. Material and Methods A monitoring and communication system between the Department of Diagnostic Radiology and Emergency Department was initiated to mark and follow all studies from the ED for which the official reading was different than the preliminary interpretation. Data analysis was performed on all studies from 1 June 2011 to 31 May 2012, based on the severity of the discrepancy, imaging modality, resident training level, and organ system. The distribution of the number of discrepancies among the different resident levels and imaging modalities was determined, as well as the distribution of three severity scores in correlation with other variables. Results The overall discrepancy rate was 1.62%. The discrepancy rate was higher for first and second year residents (1.62% and 1.96%) than for third and fourth year residents (1.35% and 1.24%). It was higher for computed tomography (2.13%) than for radiographs (1.29%) and ultrasound (0.8%) (P value < 0.01), and higher for musculoskeletal (1.61%) than non-musculoskeletal (0.99%) radiographs (P value = 0.0003). Discrepancies with severity score one constituted 35.5% of the total discrepancies, those with severity scores two and three constituted 22.9% and 41.6%, respectively. Conclusion We have demonstrated a system for follow-up of discrepancy in interpreting emergency radiology studies, and recorded the discrepancy rate, with further analysis based on different variables. In terms of quality assurance, a periodical analysis might help to reduce the number of discrepant reports by targeted intervention.

War as a positive medical educational experience

Context  There is little empirical evidence in the literature regarding the nature of the experiences of medical students during war. In this study we set out to assess and analyse the experiences of medical students and residents in Beirut, Lebanon during the 2006 Lebanon–Israel war.

Buried Penis in the Newborn

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Cynicism and other attitudes towards patients in an emergency department in a middle eastern tertiary care center.

BackgroundA caring, compassionate practitioner of the medical arts is the idealized version of what makes a good doctor. If asked to think of a painting of a doctor we most likely conjure an image of a physician sitting at a patient’s bedside checking the pulse with a concerned look on his face. The reality is however that cynicism, among other negative attitudes, is becoming more prominent among physicians and medical staff. The causes and extent of cynicism likely vary among medical departments and different cultures. In this study, we aimed to assess attitudes of medical students and physicians in an Emergency Department (ED) in Lebanon that accommodates both local patients and is also known to attract patients from around the Middle East.MethodsA total of 30 students, residents and attending physicians at the American University of Beirut Medical Center were invited to participate. All participants underwent semi-structured interviews that were recorded, transcribed and then analyzed for common themes.ResultsMore negative emotions were expressed among participants than positive ones. Negative emotions were more frequently expressed among medical students, interns and residents than attending physicians. Cynicism in the ED was commonly reported however, maintenance of professionalism and adequate patient care were underscored. While empathy was recurrently found among participants, a trend towards a decrease in empathy with career progression was noted among attending physicians. Further, negative feelings towards patient families were prominent. Participants tended to categorize patients based on willingness to cooperate, gender, age, case acuity, ethnic origins and social status.ConclusionsCynicism emerged as a prominent theme among medical students and staff in our study. However, participants were also empathetic. These attitudes were generally attributed to the peculiar stressors associated with the Lebanese culture, low acuity cases and “VIP” patients. It is crucial to explore methods in order to decrease cynicism and improve patient care. Also, the implications of these attitudes on patient care remain to be discovered.

Challenges in measuring ACGME competencies: considerations for milestones

BackgroundMeasuring milestones, competencies, and sub-competencies as residents progress through a training program is an essential strategy in Accreditation Council for Graduate Medical Education (ACGME)’s attempts to ensure graduates meet expected professional standards. Previous studies have found, however, that physicians make global ratings often by using a single criterion.MethodsWe use advanced statistical analysis to extend these studies by examining the validity of ACGME International competency measures for an international setting, across emergency medicine (EM) and neurology, and across evaluators. Confirmatory factor analysis (CFA) models were fitted to both EM and neurology data. A single-factor CFA was hypothesized to fit each dataset. This model was modified based on model fit indices. Differences in how different EM physicians perceived the core competencies were tested using a series of measurement invariance tests.ResultsExtremely high alpha reliability coefficients, factor coefficients (> .93), and item correlations indicated multicollinearity, that is, most items being evaluated could essentially replace the underlying construct itself. This was true for both EM and neurology data, as well as all six EM faculty.ConclusionsEvaluation forms measuring the six core ACGME competencies did not possess adequate validity. Severe multicollinearity exists for the six competencies in this study. ACGME is introducing milestones with 24 sub-competencies. Attempting to measure these as discrete elements, without recognizing the inherent weaknesses in the tools used will likely serve to exacerbate an already flawed strategy. Physicians likely use their “gut feelings” to judge a resident’s overall performance. A better process could be conceived in which this subjectivity is acknowledged, contributing to more meaningful evaluation and feedback.

The effect of patient death on medical students in the emergency department

BackgroundThe emotional consequences of patient deaths on physicians have been studied in a variety of medical settings. Reactions to patient death include distress, guilt, and grief. Comparatively, there are few studies on the effects of patient death on physicians and residents in the Emergency Department (ED). The ED setting is considered unique for having more sudden deaths that likely include the young and previously healthy and expectations for the clinician to return to a dynamic work environment. To date, no studies have looked at the effects of patient deaths on the more vulnerable population of medical students in the ED. This study examined aspects of patient deaths in the ED that most strongly influence students’ reactions while comparing it to those of an inpatient setting.MethodsSemi-structured qualitative interviews were carried out with a total of 16 medical students from the American University of Beirut, Medical Center in Lebanon who had recently encountered a patient death in the ED. Questions included their reaction to the death, interaction with patients and their family members, the response of the medical team, and coping mechanisms adopted.ResultsThe analysis revealed the following as determinant factors of student reaction to patient death: context of death; including age of patient, expectation of death, first death experience, relating patient death to personal deaths, and extent of interaction with patient and family members. Importantly, deaths in an inpatient setting were judged as more impactful than ED deaths. ED deaths, however, were especially powerful when a trauma case was deemed physically disturbing and cases in which family reactions were emotionally moving.ConclusionThe study demonstrates that students’ emotional reactions differ as a function of the setting (surprise and shock in the ED versus sadness and grief in an inpatient setting). Debriefing and counseling sessions on ED deaths may benefit from this distinction.