Vicki R. LeBlanc

The effects of acute stress on performance: implications for health professions education.

Purpose This paper is a review of representative research on the impact of acute stressors on the clinical performance of individuals and teams. Method The Sciences Citation Index, Medline, and Psychinfo were used to search for articles up to and including 2008. The search terms were stress/tension/arousal/anxiety/cortisol/threat, cognition/skills/memory/attention/problem solving/decision making/performance, stress reduction/stress exposure/stress management/stress inoculation, and health professionals/medicine/medical students/residents/physicians/teams. The search was limited to papers in English from all developed countries. Secondary references were selected from primary papers. Results Elevated stress levels can impede performance on tasks that require divided attention, working memory, retrieval of information from memory, and decision making. These effects appear to be determined by the individual’s appraisal of the demands and resources of a situation, the relationship between the stressor and the task, and factors such as coping styles, locus of control, and social supports. Conclusions Given the potential negative impact of stress on performance, and the individualistic way in which people respond, medical educators might want to consider avenues for training learners in stress management. More research is needed to fully understand the contributions of personal factors such as coping style and locus of control, as well as the relationship of perceptions of stress to issues such as fatigue.

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents.

Objective:We aimed to determine internal medicine residents’ perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal. Design:Cross-sectional postal survey. Setting:Canadian internal medicine training programs. Participants:Internal medicine residents attending Canadian English-speaking medical schools. Interventions:A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools. Measurements and Main Results:Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r2 = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence. Conclusions:The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.

Teaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading information

Objective  Previous research has revealed a pedagogical benefit of instructing novice diagnosticians to utilise a combined approach to clinical reasoning (familiarity‐driven pattern recognition combined with a careful consideration of the presenting features) when diagnosing electrocardiograms (ECGs). This paper reports 2 studies demonstrating that the combined instructions are especially valuable in helping students overcome biasing influences.

Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations

Medical Education 2010: 44: 587–594

Paramedic Performance in Calculating Drug Dosages Following Stressful Scenarios in a Human Patient Simulator

Background. Paramedics face many stressors in their work environment. Studies have shown that stress can have a negative effect on the psychological well-being of health professionals. However, there is little published research regarding the effects of stress on the cognitive skills necessary for optimal patient care. Objectives. The primary purpose of this study was to investigate the effects of acute stress on the emotional response andperformance of paramedics. Furthermore, the authors explored whether a paramedics level of training or years of experience would mediate the effects of stress on performance. Methods. Paramedic performances in calculating drug dosages were compared in two stress conditions. In the low-stress condition, 30 paramedics calculated the drug dosages in a quiet classroom free of any stressor. In the high-stress condition, the same paramedics calculated comparable drug dosages immediately after working through a challenging scenario with a human patient simulator. Results. The paramedics obtained lower accuracy scores in the high-stress condition than in the low-stress condition [43% (95% confidence interval [CI]: 36.9–49.2) vs. 58% (95% CI: 48.6–67.1), p < 0.01 based on univariate analysis]. Neither work experience nor level of training predicted the individual differences in the stress-induced performance decrements. Conclusion. These results suggest that the types of stressors encountered in clinical situations can increase medical errors, even in highly experienced individuals. These findings underline the need for more research to determine the mechanisms by which stress influences clinical performance, with the ultimate goal of targeting education or technologic interventions to those tasks, situations, andindividuals most likely to benefit from such interventions.

Interventions to reduce the consequences of stress in physicians: a review and meta-analysis.

Abstract A significant proportion of physicians and medical trainees experience stress-related anxiety and burnout resulting in increased absenteeism and disability, decreased patient satisfaction, and increased rates of medical errors. A review and meta-analysis was conducted to examine the effectiveness of interventions aimed at addressing stress, anxiety, and burnout in physicians and medical trainees. Twelve studies involving 1034 participants were included in three meta-analyses. Cognitive, behavioral, and mindfulness interventions were associated with decreased symptoms of anxiety in physicians (standard differences in means [SDM], −1.07; 95% confidence interval [CI], −1.39 to −0.74) and medical students (SDM, −0.55; 95% CI, −0.74 to −0.36). Interventions incorporating psychoeducation, interpersonal communication, and mindfulness meditation were associated with decreased burnout in physicians (SDM, −0.38; 95% CI, −0.49 to −0.26). Results from this review and meta-analysis provide support that cognitive, behavioral, and mindfulness-based approaches are effective in reducing stress in medical students and practicing physicians. There is emerging evidence that these models may also contribute to lower levels of burnout in physicians.

Impact of stress on resident performance in simulated trauma scenarios.

Background: Training and practice in medicine are inherently stressful. The effects of stress on performance in clinical situations are poorly understood. The purpose of this study was to examine the stress responses and clinical performance of residents during low and high stress (HS) simulated trauma resuscitations. Methods: Thirteen emergency medicine and general surgery residents were evaluated in HS and low stress (LS) trauma resuscitation simulations. Subjective and physiologic (heart rate, salivary cortisol) responses were measured at baseline and in response to the scenarios. Performance was assessed with global rating and checklist scores of technical performance, time to record critical information, and the Anesthesia Non-Technical Skills tool. Postscenario recall was assessed with the completion of a standardized trauma history form. Results: Postscenario subjective stress and cortisol levels were higher in the HS scenario compared with the LS scenario (p < 0.05). Checklist performance scores and postscenario recall were significantly lower in the HS compared with the LS condition (p < 0.05). Conclusion: In trainees, some aspects of performance and immediate recall appear to be impaired in complex clinical scenarios in which they exhibit elevated subjective and physiologic stress responses. The findings of this study highlight a potential threat to patient safety and demand further investigation. Future studies should strive to further elucidate the effects of stress on specific components of performance and investigate ways to reduce its negative impact.

Personalized Oral Debriefing Versus Standardized Multimedia Instruction After Patient Crisis Simulation

BACKGROUND: Simulation experience alone without debriefing is insufficient for learning. Standardized multimedia instruction has been shown to be useful in teaching surgical skills but has not been evaluated for use as an adjunct in crisis management training. Our primary purpose in this study was to determine whether standardized computer-based multimedia instruction is effective for learning, and whether the learning is retained 5 wk later. Our secondary purpose was to compare multimedia instruction to personalized video-assisted oral debriefing with an expert. METHODS: Thirty anesthesia residents were recruited to manage three different simulated resuscitation scenarios using a high-fidelity patient simulator. After the first scenario, subjects were randomized to either a computer-based multimedia tutorial or a personal debriefing of their performance with an expert and videotape review. After their respective teaching, subjects managed a similar posttest resuscitation scenario and a third retention test scenario 5 wk later. Performances were independently rated by two blinded expert assessors using a previously validated assessment system. RESULTS: Posttest (12.22 ± 2.19, P = 0.009) and retention (12.80 ± 1.77, P < 0.001) performances of nontechnical skills were significantly improved in the standardized multimedia instruction group compared with pretest (10.27 ± 2.10). There were no significant differences in improvement between the two methods of instruction. CONCLUSION: Computer-based multimedia instruction is an effective method of teaching nontechnical skills in simulated crisis scenarios and may be as effective as personalized oral debriefing. Multimedia may be a valuable adjunct to centers when debriefing expertise is not available.

Believing is seeing: the influence of a diagnostic hypothesis on the interpretation of clinical features.

Many clinical decisions are made on the basis of information gathered from patients, whether in the form of chief complaints, patient appearance, or physical findings. Errors made in gathering and interpreting such clinical information could result in serious consequences in patient care, such as delays or errors in treatment. Little research has been devoted to understanding the mechanisms underlying such errors. In psychology, it has long been known that context influences perception. Phenomena such as visual illusions and the word superiority effect, in which letters are more easily recognized when presented in words rather than in unrelated letter strings, are pertinent examples of how the context influences feature interpretation. Similarly, research in radiology demonstrates that information such as the location of tenderness and swelling and tentative diagnoses increases the likelihood that physicians will detect fractures and lesions. Even with less ambiguous visual stimuli, such as patient appearance or electrocardiograms, the consideration of the correct diagnosis leads to an increase in detecting clinical signs compared with having no diagnosis in mind. These studies demonstrate that the identification of clinical signs is influenced by the diagnostic hypotheses held by diagnosticians. However, by measuring only performance in reporting the depicted correct features from the clinical stimuli, these researchers do not allow for conclusions to be drawn regarding the specific influence of a diagnostic hypothesis on feature identification. Once a diagnosis is considered, it can activate a representation of the disease presentation, bringing to mind the possible features that can be visible on a patient suffering from the given condition. The diagnosticians can then run through this list of features, checking for the presence or absence of each. This diagnosis would thus serve as a focus of attention, determining which features to look for and where to look for them. Additionally, the diagnostic hypothesis might have a stronger impact of inducing a bias in the identification of the observed physical characteristics, e.g., knowing that a moon-shaped face is a feature of Cushing’s disease and believing the diagnosis to be Cushing’s might lead diagnosticians to interpret a slightly obese face as moon-shaped. This interaction between the diagnosis and feature identification, if present, might be sufficient to lead clinicians to report features that are not present in patients. Given that there are a number of clinical situations where potentially biasing effects on diagnostic suggestions can occur, such as in referral letters or patient charts, it is important to understand the impact of such suggestions on the interpretation of clinical information. In the present study, we investigated whether the influence of the diagnosis (and accompanying brief case history) is strong enough to bias the interpretation of clinical information. Medical students and residents are suggested either the correct diagnosis or an alternate but plausible diagnosis prior to reporting all clinically important features from photographs of patients. If a diagnosis simply focuses attention on the relevant features, participants who are biased toward an alternate diagnosis should report fewer of the correct features than participants biased toward a correct diagnosis. However, the two groups should not differ in terms of reporting features that are consistent with the alternate diagnosis but not present in the photograph. Alternatively, if a diagnostic hypothesis does change the interpretation provided to the clinical data, participants biased toward an alternate diagnosis should be more likely to misinterpret correct features or normal variations in appearance as features supporting the alternate diagnosis. Therefore, they should report more alternate features than participants biased toward the correct diagnosis.

On the Difficulty of Noticing Obvious Features in Patient Appearance

Medical students and experts were given head-and-shoulder photographs of patients, each showing a key feature of the patients problem. Three quarters of these pictures were taken from textbooks. Noticing these supposedly obvious features was difficult and strongly influenced by contextual factors. Both experts and students gained about 20% in diagnostic accuracy by having the key features verbally described for them, although these were clearly visible on the photographs. Conversely, both experts and students reported seeing more of these features when the correct diagnosis was suggested to them. This facilitation resulted from an increase in sensitivity to depicted features, rather than a response bias. The properties of these features that allow such failures of noticing are discussed.