Robert L. Trowbridge

Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism.

Purpose To determine if CT variables predict in-hospital morbidity and mortality in patients with pulmonary embolism (PE). Materials and Methods CT scans and charts of 173 patients with CT scans positive for PE were reviewed. CT scans were reviewed for leftward ventricular septal bowing, increased right ventricle (RV) to left ventricle (LV) diameter ratio, clot burden, increased pulmonary artery to aorta diameter ratio, and oligemia. Charts were reviewed for severe morbidity and mortality outcomes: death from pulmonary emboli or any cause, and cardiac arrest. Charts were also reviewed for milder morbidity outcomes: intubation, vasopressor use, or admission to an intensive care unit (ICU) and for multiple comorbidities. Results No CT predictor was significantly associated with severe morbidity or mortality outcomes. Ventricular septal bowing and increased RV/LV diameter ratio were both associated with subsequent admission to an ICU (P = 0.004 and P = 0.025, respectively). Oligemia (either lung) was associated with subsequent intubation; right lung oligemia was associated with the subsequent use of vasopressors. After controlling for history of congestive heart failure, ischemic heart disease, and pulmonary disease, both septal bowing and an increased RV/LV diameter ratio remained associated with admission to an ICU. Conclusion No CT variables predicted severe in-hospital morbidity and mortality (death from pulmonary embolism, death from any cause, or cardiac arrest) in patients with PE. However, ventricular septal bowing and increased RV/LV diameter ratio were both strongly predictive of less severe morbidity, namely, subsequent ICU admission, and oligemia was associated with subsequent intubation and vasopressor use.

Why Medical Educators May Be Failing at Feedback

IN THE 25 YEARS SINCE ENDE 1 PUBLISHED THE SEMINAL ARticle on feedback in clinical medical education, many of the concepts have been verified and repeatedly emphasized. However, physicians participating in needs assessments for faculty development frequently cite feedback as an area for improvement. Considering the provision of feedback as a competency is quite appropriate, because feedback is an essential skill for learner improvement. Without effective feedback, learners struggle to achieve defined goals. Despite the focus on feedback, learners may still perceive a lack, even when explicitly informed that feedback is occurring. The stark difference between what teachers think they are delivering and what learners think they are receiving begs the question: are medical educators failing at promoting effective feedback? Some evidence indicates that feedback is not being provided effectively. Learners still complain about not receiving enough feedback. Verbal interaction analysis indicates that the feedback dialogue is too teacher centered and is skewed toward predominantly the positive or neutral. Feedback may be provided at a low cognitive level using basic and descriptive facts, precluding active engagement of the learner. Students’ dissatisfaction with feedback may reflect a greater desire for praise than for constructive information to help them learn. Desires for mainly positive feedback may become a worsening trend as the “Millennial Generation” enters US medical schools. This generation has been broadly characterized as being raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback. These studies suggest that educators might not be providing learners with effective feedback. Possible reasons are use of incorrect measures of success (eg, Likert-type student satisfaction scales) or insufficient faculty development programs. Such arguments tend to focus on external factors (such as increased productivity pressures) or teacherbased behaviors. The feedback dialogue has been overly centered on the role of the teacher while underemphasizing the role of the learner. As such, 3 potential reasons may help account for failing at feedback: poor ability of learners for selfassessment, overpowering influence of affective reactions to feedback, and lack of adequately developed metacognitive capacities. There is increasing evidence that physicians, as a group of professionals, have little ability to accurately self-assess performance and typically tend to overestimate abilities. This distorting cognitive process could be the result of a strong need to protect self-image. Physician-learners may be poor at assessing their own capabilities; even worse, the most deficient performers may be least aware of their lack of competence. A dangerous medical professional is one who is unaware of what he or she does not know and lacks the skills and insight necessary for self-assessment. Learners who tend to overestimate their own abilities may be surprised when they receive feedback incongruent with their self-perceptions. This conflicting feedback could generate more of an emotional reaction than an unemotional review of the facts, driven by feedback lessons unconsciously stored in memory from years past, possibly even from childhood experiences. Learners could view negative feedback as a personal attack. Since learners are motivated to defend their egos and often prefer information that supports their positive self-views, these attacks on the ego can trigger negative emotional reactions such as guilt, anger, or self-doubt, often at an unconscious level. These emotions can in turn block any useful feedback from reaching the learner at some cognitive level, creating an insurmountable barrier. Learners with distressing reactions to feedback tend to devalue it as not useful. Damage to the learner’s self-image by constructive feedback could lead to learners using cognitive mechanisms to protect themselves from narcissistic injury (eg, outright denial, distorting information). Discounted feedback would not result in improved learner performance. Learners with more positive self-esteem and stronger egos may seek both positive and negative feedback, whereas learners with lower self-esteem may seek only positive feedback. The latter may avoid feedback interactions as a selfprotective mechanism.

Twelve tips for teaching avoidance of diagnostic errors.

Background: Despite an increasing emphasis on patient safety on the part of healthcare systems worldwide, diagnostic error remains common. Errors frequently result in significant clinical consequences and persist despite remarkable advances in diagnostic technology. Most medical students and physician trainees receive little instruction regarding both the root causes of diagnostic errors and how to avoid such errors. Aims: This installment of the ‘12 tips’ series discusses how to familiarize the learner with the cognitive underpinnings of diagnostic error. It also describes how to teach several approaches to the diagnostic process that may lessen the likelihood of error. Methods: Specific educational practices are discussed in detail. Emphasis is placed on describing meta-cognitive techniques, promoting the value of the clinical examination, and employing simple diagnostic strategies, including ‘diagnostic time-outs’ and the practice of ‘worst-case scenario’ medicine. Conclusions: Clinical educators may help learners avoid diagnostic errors by employing several of the educational techniques described herein.

The Next Organizational Challenge: Finding and Addressing Diagnostic Error

BACKGROUND Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to identify cases of diagnostic error. WHY HEALTH CARE ORGANIZATIONS NEED TO GET INVOLVED: HCOs are preoccupied with many quality- and safety-related operational and clinical issues, including performance measures. The case for paying attention to diagnostic errors, however, is based on the following four points: (1) diagnostic errors are common and harmful, (2) high-quality health care requires high-quality diagnosis, (3) diagnostic errors are costly, and (4) HCOs are well positioned to lead the way in reducing diagnostic error. FINDING DIAGNOSTIC ERRORS: Current approaches to identifying diagnostic errors, such as occurrence screens, incident reports, autopsy, and peer review, were not designed to detect diagnostic issues (or problems of omission in general) and/or rely on voluntary reporting. The realization that the existing tools are inadequate has spurred efforts to identify novel tools that could be used to discover diagnostic errors or breakdowns in the diagnostic process that are associated with errors. New approaches--Maine Medical Centers case-finding of diagnostic errors by facilitating direct reports from physicians and Kaiser Permanentes electronic health record--based reports that detect process breakdowns in the followup of abnormal findings--are described in case studies. CONCLUSION By raising awareness and implementing targeted programs that address diagnostic error, HCOs may begin to play an important role in addressing the problem of diagnostic error.

Educational agenda for diagnostic error reduction

Diagnostic errors are a major patient safety concern. Although the majority of diagnostic errors are partially attributable to cognitive mistakes, the most effective means of improving clinician cognition in order to achieve gains in diagnostic reliability are unclear. We propose a tripartite educational agenda for improving diagnostic performance among students, residents and practising physicians. This agenda includes strengthening the metacognitive abilities of clinicians, fostering intuitive reasoning and increasing awareness of the role of systems in the diagnostic process. The evidence supporting initiatives in each of these realms is reviewed and a course of future implementation and study is proposed. The barriers to designing and implementing this agenda are substantial and include limited evidence supporting these initiatives and the challenges of changing the practice patterns of practising physicians. Implementation will need to be accompanied by rigorous evaluation.

The Effect of Overnight In-House Attending Coverage on Perceptions of Care and Education on a General Medical Service

BACKGROUND An increased emphasis on patient safety has led to calls for closer supervision of medical trainees. It is unclear what effect an increased degree of faculty presence will have on educational and clinical outcomes. The aim of this study was to evaluate resident and attending attitudes and preferences regarding overnight attending supervision. METHODS This study was a cross-sectional electronic survey of physicians. Participants were resident and faculty physicians recently on inpatient service rotations after implementation of an overnight attending coverage system. RESULTS Of 58 total respondents, most faculty (91%) and resident (92%) physicians reported they were satisfied with the overall quality of care delivered and believed the quality of care delivered overnight improved with an in-house attending system (90% and 85%, respectively). Most resident physicians (82%) believed the educational experience improved with the system of increased attending availability. Nearly all faculty (95%) and resident (97%) physicians preferred the in-house attending system to the traditional system of attendings being available by pager. The implementation of such coverage resulted in increased cost to the hospital for compensating covering hospitalist physicians. CONCLUSION In-house attending coverage was acceptable to both residents and faculty, with perceived improvements in quality and educational experience.

A systematic review of the use and effectiveness of the Objective Structured Teaching Encounter

Background: The Objective Structured Teaching Encounter (OSTE) has been proposed as a means of promoting and assessing the teaching skills of medical faculty. Aims: To describe the uses of the OSTE and the evidence supporting its effectiveness. Method: MEDLINE (January 1966 through February 2010) was searched for English-language studies detailing the use of an OSTE for any educational purpose. Reference lists from relevant review articles and identified studies were also searched. Of the 354 papers initially identified, 22 were included in the review. Results: The OSTE has been used to assess and improve teaching performance and to assess the impact of other means of faculty development. Although qualitative results have been generally positive, there is little quantitative data to support using the OSTE as a means of improving teaching performance. There is moderate evidence suggesting the OSTE is a reliable and valid means of assessing teaching, although few ratings instruments have been adequately studied. Conclusions: The OSTE is a promising innovation with potential application to assessing and promoting the teaching skills of medical faculty. Further study is required to determine the most effective OSTE design.

Feedback for Learners in Medical Education: What Is Known? A Scoping Review

Purpose To conduct a scoping review of the literature on feedback for learners in medical education. Method In 2015–2016, the authors searched the Ovid MEDLINE, ERIC, CINAHL, ProQuest Dissertations and Theses Global, Web of Science, and Scopus databases and seven medical education journals (via OvidSP) for articles published January 1980–December 2015. Two reviewers screened articles for eligibility with inclusion criteria. All authors extracted key data and analyzed data descriptively. Results The authors included 650 articles in the review. More than half (n = 341) were published during 2010–2015. Many centered on medical students (n = 274) or residents (n = 192); some included learners from other disciplines (n = 57). Most (n = 633) described methods used for giving feedback; some (n = 95) described opinions and recommendations regarding feedback. Few studies assessed approaches to feedback with randomized, educational trials (n = 49) or described changes in learner behavior after feedback (n = 49). Even fewer assessed the impact of feedback on patient outcomes (n = 28). Conclusions Feedback is considered an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches. The literature on feedback for learners in medical education is broad, fairly recent, and generally describes new or altered curricular approaches that involve feedback for learners. High-quality, evidence-based recommendations for feedback are lacking. In addition to highlighting calls to reassess the concepts and complex nature of feedback interactions, the authors identify several areas that require further investigation.

Commentary: Principle-Based Teaching Competencies

The emphasis on resident competencies advocated by the Accreditation Council for Graduate Medical Education and other medical educators1 has brought new focus on the teaching competencies of our faculty. The expectation that teaching faculty possess a minimum level of teaching competency has been under discussion at our institution. In our recent (2008) peer-reviewed workshop at the Association of American Medical Colleges, we found that, among the 28 participants, no school was providing faculty development for competence in teaching. As increasing public scrutiny focuses on the medical professions, medical educators will be asked to be more accountable for training programs they are involved in and the teaching skills they possess.2

Use of a novel, modified fishbone diagram to analyze diagnostic errors

Abstract Diagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.