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ABSTRACT: Attributes of the organisational culture of residency training programmes may impact patient safety. Training environments are complex, composed of clinical teams, residency programmes, and clinical units. We examined the relationship between residents' perceptions of their training environment and disclosure of or apology for their worst error.
Anonymous, self-administered surveys were distributed to Medicine and Surgery residents at Boston Medical Center in 2005. Surveys asked residents to describe their worst medical error, and to answer selected questions from validated surveys measuring elements of working environments that promote learning from error. Subscales measured the microenvironments of the clinical team, residency programme, and clinical unit. Univariate and bivariate statistical analyses examined relationships between trainee characteristics, their perceived learning environment(s), and their responses to the error.
Out of 109 surveys distributed to residents, 99 surveys were returned (91% overall response rate), two incomplete surveys were excluded, leaving 97: 61% internal medicine, 39% surgery, 59% male residents. While 31% reported apologising for the situation associated with the error, only 17% reported disclosing the error to patients and/or family. More male residents disclosed the error than female residents (p=0.04). Surgery residents scored higher on the subscales of safety culture pertaining to the residency programme (p=0.02) and managerial commitment to safety (p=0.05). Our Medical Culture Summary score was positively associated with disclosure (p=0.04) and apology (p=0.05).
Factors in the learning environments of residents are associated with responses to medical errors. Organisational safety culture can be measured, and used to evaluate environmental attributes of clinical training that are associated with disclosure of, and apology for, medical error.
BMJ quality & safety 09/2011; 21(4):271-8.
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ABSTRACT: Community health centers are facing a shortage of primary care physicians at a time when government plans have called for an expansion of community health center programs. To succeed with this expansion, community health centers require additional well-trained physician leadership. Our objective was to ascertain how medical directors obtain leadership skills in an attempt to identify the best methods and venues for providing future leadership training programs.
Using recorded interviews and focus group data with community health center medical directors, we identified patterns and themes through cross-case content analysis to determine leadership training needs in underserved settings.
Medical directors often enter positions unprepared and can quickly become frustrated by an inability to make system improvements. Medical directors seek multiple ways to obtain the leadership skills necessary, including conferences, peer networking, mentorship, and formal degree training. Many directors express a desire for additional training, preferring flexibility in curriculum and hands-on components.
Additional leadership training opportunities for active and future medical directors are needed. Academic medical centers and other training sponsors should consider innovative ways to develop effective physician leadership to provide quality care to underserved communities.
Family medicine 06/2010; 42(6):403-7. · 1.33 Impact Factor
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ABSTRACT: Studies show that measures of physician and medical students' empathy decline with clinical training. Presently, there are limited data relating self-reported measures to observed behavior. This study explores a self-reported measure and observed empathy in medical students.
Students in the Class of 2009, at a university-based medical school, were surveyed at the end of their 2nd and 3rd year. Students completed the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a self-administered scale, and were evaluated for demonstrated empathic behavior during Objective Structured Clinical Examinations (OSCEs).
97.6% and 98.1% of eligible students participated in their 2nd and 3rd year, respectively. The overall correlation between the JSPE-S and OSCE empathy scores was 0.22, p < 0.0001. Students had higher self-reported JSPE-S scores in their 2nd year compared to their 3rd year (118.63 vs. 116.08, p < 0.0001), but had lower observed empathy scores (3.96 vs. 4.15, p < 0.0001).
Empathy measured by a self-administered scale decreased, whereas observed empathy increased among medical students with more medical training.
Journal of General Internal Medicine 12/2009; 25(3):200-2. · 2.83 Impact Factor
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ABSTRACT: Literature reviews indicate that the proportion of clinical educational time devoted to bedside teaching ranges from 8% to 19%. Previous studies regarding this paucity have not adequately examined the perspectives of learners. The authors explored learners' attitudes toward bedside teaching, perceptions of barriers, and strategies to increase its frequency and effectiveness, as well as whether learners' stages of training influenced their perspectives.
Six focus group discussions with fourth-year medical students and first- or second-year internal medicine residents recruited from the Boston University School of Medicine and Residency Program in Internal Medicine were conducted between June 2004 and February 2005. Each 60- to 90-minute discussion was audiotaped, transcribed, and analyzed using qualitative methods.
Learners believed that bedside teaching is valuable for learning essential clinical skills. They believed it is underutilized and described many barriers to its use: lack of respect for the patient; time constraints; learner autonomy; faculty attitude, knowledge, and skill; and overreliance on technology. Learners suggested a variety of strategies to mitigate barriers: orienting and including the patient; addressing time constraints through flexibility, selectivity, and integration with work; providing learners with reassurance, reinforcing their autonomy, and incorporating them into the teaching process; faculty development; and advocating evidence-based physical diagnosis. Students focused on the physical diagnosis aspects of bedside teaching, whereas views of residents reflected their multifaceted roles as learners, teachers, and managers.
Bedside teaching is valuable but underutilized. Including the patient, collaborating with learners, faculty development, and promoting a supportive institutional culture can redress several barriers to bedside teaching.
Academic Medicine 04/2008; 83(3):257-64. · 3.52 Impact Factor
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ABSTRACT: A 51-year-old male with a history of insulin-dependent diabetes and polysubstance abuse presented after overdose on insulin. Soon after resuscitation, he displayed a severe ataxia in all 4 limbs and was unable to walk; all of which persisted for at least 5 days. Laboratory testing was unrevealing, including relatively normal brain magnetic resonance imaging. He had recovered full neurologic function 3 months after the event. This report describes a case of reversible cerebellar ataxia as a rare complication of severe hypoglycemia that may occur in patients with abnormal cerebellar glucose metabolism. Thus, this phenomenon should be included in the differential diagnosis of patients with a history of hypoglycemia who present with ataxia. In this context, the differential diagnosis of cerebellar ataxia is discussed, as is the proposed mechanism for hypoglycemia-induced cerebellar dysfunction.
Journal of General Internal Medicine 02/2008; 23(1):103-5. · 2.83 Impact Factor
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Jay D Orlander
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ABSTRACT: Little has been written on the art of using a board in clinical teaching. The technological development of the white board appears to have coincided with that of the laptop computer and accompanying LCD projector, so that fewer and fewer teaching sessions appear to utilize the board as an efficient teaching tool. I have observed this most commonly among younger faculty who are most comfortable with technology and who may lack training and experience with a blank board. This paper offers suggestions on using the board in clinical teaching in order to enhance the educational process through better engagement of the learners.
Medical Teacher 04/2007; 29(2-3):89-92. · 1.22 Impact Factor
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ABSTRACT: To describe black residents' perceptions of the impact of race on medical training.
Open-ended interviews were conducted of black physicians in postgraduate year 22 who had graduated from U.S. medical schools and were enrolled in residency programs at one medical school. Using Grounded Theory tenets of qualitative research, data was culled for common themes through repeated readings; later, participants commented on themes from earlier interviews.
Of 19 participants 10 were male, distributed evenly among medical and surgical fields. Four major themes emerged from the narratives: discrimination, differing expectations, social isolation and consequences. Participants' sense of being a highly visible minority permeated each theme. Overt discrimination was rare. Participants perceived blacks to be punished more harshly for the same transgression and expected to perform at lower levels than white counterparts. Participants' suspicion of racism as a motivation for individual and institutional behaviors was tempered by self-doubt. Social isolation from participants' white colleagues contrasted with connections experienced with black physicians, support staff and patients, and participants strongly desired black mentors. Consequences of these experiences varied greatly.
Black physicians face complex social and emotional challenges during postgraduate training. Creating supportive networks and raising awareness of these issues may improve training experiences for black physicians.
Journal of the National Medical Association 10/2006; 98(9):1441-8. · 1.16 Impact Factor
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ABSTRACT: This study sought to determine the prevalence and characteristics of morbidity and mortality conferences (M&MCs) in U.S. internal medicine training programs. Two hundred ninety-five of 416 (71%) surveys were returned. Ninety percent of programs have an M&MC. Most meet monthly, have a designated leader, and entail case discussions of 3 or fewer patients. Cases are selected on the basis of unexpected bad outcomes, teaching value, and to a lesser extent, suspected medical error. Two thirds of the sites use M&MCs to meet administrative requirements for quality assurance. M&MC, while prevalent in internal medicine training programs, has a heterogeneity of focus. Hence, the goals and role of the conference, as judged by this survey, do not appear to be well defined and may warrant further clarification.
Journal of General Internal Medicine 08/2003; 18(8):656-8. · 2.83 Impact Factor
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ABSTRACT: Previous reports document diminishing time spent on bedside teaching, with a shift towards conference rooms and corridors. This study explored faculty's perceptions of the barriers to and their strategies for increasing and improving bedside teaching.
Four focus groups consisting of (1) chief residents, (2) residency program directors, (3) skilled bedside teachers, and (4) a convenience group of other Department of Medicine faculty from the Boston University School of Medicine's affiliated hospitals were held in May 1998. Each session lasted 60-90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods.
The most significant barriers reported were (1) declining bedside teaching skills; (2) the aura of bedside teaching, a belief that bedside teachers should possess an almost unattainable level of diagnostic skill that creates intense performance pressure; (3) that teaching is not valued; and (4) erosion of teaching ethic. Focus-group participants suggested the following strategies for addressing these barriers: improve bedside teaching skills through faculty training in clinical skills and teaching methods; reassure clinical faculty that they possess more than adequate bedside skills to educate trainees; establish a learning climate that allows teachers to admit their limitations; and address the undervaluing of teaching on a department level with adequate recognition and rewards for teaching efforts. Skilled teachers, in particular, stated that a bedside teaching ethic could be reestablished by emphasizing its importance and challenging learners to think clinically.
Bedside teaching is regarded as valuable. Some barriers may be overcome by setting realistic faculty expectations, providing incentives for teaching faculty, and establishing ongoing faculty development programs.
Academic Medicine 05/2003; 78(4):384-90. · 3.52 Impact Factor
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ABSTRACT: Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors' formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process.
To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills.
Confidential mailed survey.
All medicine house officers at 2 urban, university-based residency programs in Boston.
Details of medical residents' first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training.
One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8).
Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.
Journal of General Internal Medicine 12/2002; 17(11):825-31. · 2.83 Impact Factor
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ABSTRACT: CONTEXT: Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors' formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process.OBJECTIVE: To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills.DESIGN: Confidential mailed survey.SETTING AND SUBJECTS: All medicine house officers at 2 urban, university-based residency programs in Boston.MAIN OUTCOME MEASURES: Details of medical residents' first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training.RESULTS: One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8).CONCLUSION: Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.
Journal of General Internal Medicine 10/2002; 17(11):825 - 840. · 2.83 Impact Factor
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ABSTRACT: The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.
Academic Medicine 10/2002; 77(10):1001-6. · 3.52 Impact Factor
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ABSTRACT: The art of teaching is difficult to master. When teaching in small groups, as often happens in clinical medicine, there is
an opportunity to find out what works by speaking directly with students. The information they provide can serve as an invaluable
guide, permitting refinement of skill over time. There are, however, significant barriers to this process. The art lies in
finding an approach that is comfortable for both parties. The authors refer to this activity as soliciting feedback. They
offer guidelines for soliciting feedback as an aid to improving teaching efforts.
Journal of General Internal Medicine 01/1994; 9(6):334-335. · 2.83 Impact Factor
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ABSTRACT: The ability to meet patient needs at the end of life is important. Boston University Residency Program in Medicine initiated a 1-week-long end-of-life curriculum that included a hospice care orientation, core articles, and home hospice visits. Evaluated was the impact of the rotation on participant knowledge and attitude. Knowledge was assessed by pretest and posttest questionnaires and compared with more senior resident controls, naïve to the curriculum. Attitudes toward issues relating to end-of-life care and subjective change in knowledge were assessed comparing subjects' retrospective preintervention and postintervention responses included in the postintervention questionnaire. Forty-five second-year participants completed both questionnaires. Participants demonstrated significant improvements in attitude and self-assessed knowledge of end-of-life care in 23 of 24 Likert-type scale questions. The end-of-life curriculum led to significant improvements in participant knowledge and attitudes about the conceptual and practical aspects of end-of-life care. The structure of the rotation should be reproducible in many locales.
American Journal of Hospice and Palliative Medicine 23(6):439-46. · 1.15 Impact Factor
