Benefits And Harms Of “Close Supervision” Of Residents

Supervision: This single-center rigorous randomized controlled trial of level of attending supervision on a large inpatient general internal medicine service adds data to the debate about the “right” level of resident supervision.  Twenty-two attending physicians were randomized to standard practice or increased work-rounds supervision over different 2-week rotations, leading to the observation of 44 blocks.  Standard supervision (at Massachusetts General Hospital) consists of bedside presentations to the attending of all new patients and a “card-flip” on established patients following-resident-led work rounds.  In the intervention arm, attendings “joined both new patient presentations and resident work rounds 7 days a week, providing direct supervision during work rounds.”  Multiple outcomes were tracked including medical errors discovered by rigorous investigation, other patient outcomes, time-motion observations of rounds, tracking of orders and consultations, and survey responses of interns, residents, and attendings.  There were slightly but not significantly more errors in the standard supervision arm, but nearly all the errors were mild.  Only two severe errors were discovered, one in each group.  General patient outcomes, e.g. length of stay, mortality, transfer to the ICU, etc. were indistinguishable, as were number of orders and consultations.  Time-motion studies showed that work rounds were 202 minutes (!) under both conditions and that interns spoke about 10 fewer minutes during work rounds which included the attending.  The biggest differences were found in the survey data:  Interns and residents overall preferred standard supervision with large differences in the numbers agreeing that autonomy and supervision were “just right” (e.g. 97% vs. 58%) and many more agreeing that their “comfort in making independent patient care decisions improved”.  Resident and interns felt they provided very good patient care under both levels of supervision.  Attendings felt that that knew their team’s plan of care better with the enhanced supervision of work rounds.  Among attendings evaluating the periods of intensive vs. standard supervision, there were statistically borderline increases in agreement with two statements:  “we provided outstanding quality of care” and “work-life balance was poor”.   For this reviewer, the large improvement in resident autonomy, possibly leading to better care by these doctors in the future, should carry weight in this on-going discussion. — Laura Willett, MD

Finn KM, Metlay JP, Chang Y, Nagarur A, Yang S, Landrigan CP, Iyasere C. Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial. JAMA Intern Med. 2018 Jun.

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Can Doctors Be Taught To Deliver Bad News?

Communication: Yes, is the short answer given in this meta-analysis of 17 studies evaluating interventions to “improve the communication of bad or difficult news”.  Most interventions were fairly brief stand-alone interventions involving simulation or role-play; the SPIKES model was the most commonly used framework for instruction.  The two most commonly assessed outcomes were observer-rated skill during a simulation exercise and physician self-rated confidence.  Both of these measures showed robust short-term improvement following training.  The authors mention the desirability of looking at longer-term outcomes and patient-centered outcomes.  This reviewer would advise some caution on measuring the latter.  Prior work has shown that patients with Stage 4 incurable cancers who did not understand they were terminally ill rated their oncologists’ communication skills better than patients who accurately understood their situation. — Laura Willett, MD

Johnson J, Panagioti M. Interventions to Improve the Breaking of Bad or Difficult News by Physicians, Medical Students, and Interns/Residents: A Systematic Review and Meta-Analysis. Acad Med. 2018 Jun

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Don’t Know Much About…..Measuring Teamwork

Teamwork: Everyone agrees that the ability to work in teams is an important competency, but how do we know that our learners have achieved this?  One observer joined 20 internal medicine housestaff teams for one morning work rounds and evaluated them using 9 different published teamwork observation instruments.  The instruments for the most part included items in the same 5 domains: team structure, leadership, situation monitoring, mutual support, and communication.  All of the tools identified the same low outlier team, but other than that one agreement, there was wide variation in the ranking of the different teams by different instruments.  If ratings of teamwork are to become high-stakes, we would hope for more robust measurement tools. — Laura Willett, MD

Weingart SN, Yaghi O, Wetherell M, Sweeney M. Measuring Medical Housestaff Teamwork Performance Using Multiple Direct Observation Instruments: Comparing Apples and Apples.  Acad Med. 2018 Apr

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Hooray For The New CMS Rules On Student Notes!

Electronic Medical Records: This is not a study, but definitely required reading for anyone in the US who deals with medical students or electronic medical records.  The prior US billing regulations “inadvertently hampered medical education and increased the administrative and regulatory burden on the teaching physician”.  In the new regulations, physicians are not required to re-document anything adequately documented by the student, but must attest to their physical presence and involvement in the history, exam, and medical decision-making.  The authors urge all health systems with medical students to “evolve their internal policies” to improve medical student learning and to “reward rather than punish the act of precepting” by improving preceptors’ documentation efficiency.  A simple and efficient way to comply with the new regulations is for the physician to listen to the student’s history presentation in the presence of the patient (who can correct the student), followed by examination and medical decision-making done by the physician and shared with the student. — Laura Willett, MD

Power DV, Byerley JS, Steiner B. Policy Change from the Centers for Medicare and Medicaid Services Provides an Opportunity to Improve Medical Student Education and Recruit Community Preceptors. Acad Med. 2018 Apr

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Feedback About Feedback

Feedback: In this qualitative study, investigators held focus groups and individual interviews with residents and faculty in the internal medicine department at Brigham and Women’s Hospital (Boston), looking into the “culture” of feedback.  Reviewers looked at transcripts and identified three major themes:  “normalizing constructive feedback to promote a culture of growth, overcoming the mental block to feedback seeking, and hierarchical culture impeding bidirectional feedback.”  Many barriers to honest constructive feedback were mentioned:  fear of damaging the relationship, fear of damaging the team dynamic, lack of comfort with giving feedback to a superior, fear of retaliation from the institution for giving negative feedback, fear of threatening the recipient’s self-esteem, and fear of threatening the reputation of the institution.  Lots of facilitators of useful feedback were also mentioned: normalizing weakness (e.g. superiors admitting their own limitations), attention to the language and tone of constructive feedback, and training in feedback delivery and feedback seeking.  Many physicians felt that longitudinal relationships made giving feedback easier, and that direct observation facilitated feedback, although some residents “saw the presence of a faculty observer as intrusive and a potential threat to autonomy.” — Laura Willett, MD

Ramani S, Könings KD, Mann KV, Pisarski EE, van der Vleuten CPM. About Politeness, Face, and Feedback: Exploring Resident and Faculty Perceptions of How Institutional Feedback Culture Influences Feedback Practices. Acad Med. 2018 Mar

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How To Help Residents Publish

Publishing: This single-site study is required reading for residency program directors and research directors.  The investigators identified all internal medicine resident projects from 2006-2013 by using departmental files and institutional review board (IRB) applications; 55% of these identified projects had resulted in a publication.  In a multivariate model, use of the (free to the user) biostatistics core was the strongest statistically significant predictor of a research project resulting in publication.  The authors mention that the biostatistics core support included help with study design, statistical analysis, writing sections of the manuscript, and addressing reviewer comments.  Projects of residents who were US (vs. international) medical graduates and who had prior publications were somewhat more likely to be published.  The residents with a research mentor having more than 5 publications were much more likely to publish, but this association  just missed statistical significance.  Residents identified as being involved in a research project were surveyed after graduation.  Only 38% responded; 69% of the respondents had published their research, suggesting possible response bias.  In survey responses, unpublished residents were more likely to cite an “uninvolved mentor” as a major barrier.  Published residents were more likely to agree that their mentors were “easily available” and “set expectations”.  “Lack of time” was a barrier cited equally by published and unpublished residents. — Laura Willett, MD

Atreya AR, Stefan M, Friderici JL, Kleppel R, Fitzgerald J, Rothberg MB Characteristics of Successful Internal Medicine Resident Research Projects: Predictors of Journal Publication Versus Abstract Presentation. Acad Med. 2018 Feb

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The “Hidden Curriculum” Strikes Again

Hidden Curriculum: Authors of this small but concerning qualitative study interviewed 15 surgical residents at one program in Canada regarding “impression management” – how individuals strive to actively manage their external image.  These trainees “described being immersed in an environment where they felt pressures to perform a set a strongly normative – but tacit – expectations to be ‘all-knowing’, ‘quick’, ‘decisive’, and ‘confident’.”  They described trying to give “an impression of competence to improve evaluations and afford learning opportunities” as well as to avoid getting a potentially irreversible negative reputation in their program.  There were some positive benefits of impression management such as “building confidence in oneself and building patients’ trust,” but there were many reported negative consequences.  These included:  inaccurate reporting (e.g. that a lab was normal when it was not checked); avoiding asking questions when uncertain; avoiding asking for help; worsened  psychological strain on the resident; and a focus on image or shame as opposed to learning.  Several reported vignettes included behaviors that could impair patient safety and/or resident learning.  The authors urge the creation of “a culture that truly encourages residents to admit knowledge gaps and ask for help when needed.” — Laura Willett, MD

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Patel P, Martimianakis MA, Zilbert NR, Mui C, Mobilio MH, Kitto S, Moulton CA., Fake It ‘Til You Make It: Pressures to Measure Up in Surgical Training. Acad Med. 2017 Dec.