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Medical Education In Cases Series | Volume 2 1
MEDICAL EDUCATION!
IN CASES
VOLUME 2
FIRST EDITION
CHAN MCCOLL LUCKETT-GATOPOULOS PURDY THOMA
Medical Education In Cases Series | Volume 2 i
ALiEM
MEDICAL EDUCATION!
IN CASES
Medical Education In Cases Series | Volume 2 ii
Editors
Editor-in-Chief!
Teresa Chan, BEd, MD, FRCPC, MHPE(c)!
!
Associate Editors!
Sarah Luckett-Gatopoulos, MSc, MD, FRCPC(c) !
Tamara McColl, MD, MHPE(c), FRCPC(c)!
Eve Purdy, MD, FRCPC(c), MA(c)!
Brent Thoma, MA, MD, FRCPC, MHPE(c)!
!
Copy Editor!
J. Bruce Blain, BA, MA, LLB
Foreword!
Alireza Jalali, MD!
Case Authors (in order of appearance)!
Heather Murray, MD, MSc, FRCPC!
Joanna Bostwick, MD, CCFP!
S. Luckett-Gatopoulos, MD, FRCPC(c)!
Eve Purdy, MD, FRCPC(c)!
Stephen Singh, MD, CCFP!
Amy Walsh, MD, MPH!
Alvin Chin, MSc, MD (c)!
Brent Thoma, MA, MD, FRCPC(c), MHPE(c)!
Isabelle Colmers, MSc, MD(c)!
Rebecca Wood, MBBS
Contributors
Medical Education In Cases Series | Volume 2 iii
Expert Commentary Authors (in order of appearance)!
Brian Goldman, MD, FACEP, MCFP(EM), FCFP!
Liz Crow, MSW, PhD(c)!
Hans Rosenberg, MD, CCFP(EM)!
Tessa Davis, MBChB, MA, FACEM!
Jennifer Tang, BHSc, MD, MHSc (Bioethics), FRCPC !
Seth Trueger, MD, MPH!
Alim Pardhan, MD, FRCPC, MBA!
Rob Rogers, MD !
Ashley Shreves MD!
Susan Shaw MD, FRCPC!
Ashley Lucas, RN, MA(c)!
Jennifer Thompson, MD, FRCPC(c)!
Gus Garmel, MD, FACEP, FAAEM!
Edwin Leap, MD!
Anton Helman, MD, CCFP(EM)!
Merril Pauls, MD, CCFP(EM), MHSc!
Kari Sampsel, MSc, MD, FRCPC, DipForSci!
Brent Thoma, MA, MD, FRCPC(c), MHPE(c)!
Jacky Parker, MBBS, MHSc CCFP(EM)
Community Curators!
Teresa Chan, BEd, MD, FRCPC, MHPE(c)!
Tamara McColl, MD, FRCPC(c), MHPE(c)!
Heather Murray, MSc, MD, FRCPC!
S. Luckett-Gatopoulos, MSc, MD, FRCPC(c)!
Eve Purdy MD, FRCPC(c)
Photo Contributors!
Teresa Chan HBSc, BEd, MD, FRCPC, MHPE(c)!
J. Bruce Blain, BA, MA, LLB
Thanks also to all our online community discussion participants. Please note your
participation is listed in each of the chapters wherein you contributed to the online
discussions.
NB: (c) denotes that current candidacy for degree or title.
Medical Education In Cases Series | Volume 2 iv
MEDICAL EDUCATION!
IN CASES
VOLUME 2
FIRST EDITION
Editors
Teresa M. Chan!
Sarah Luckett-Gatopoulos !
Tamara McColl!
Eve Purdy!
Brent Thoma
Academic Life in Emergency Medicine!
ALiEM.com
Medical Education In Cases Series | Volume 2 v
Published by Academic Life in Emergency Medicine, !
San Francisco, California, USA.
First edition, April 2016.
!
Available for usage under the Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 Unported!License.
ISBN: 978-0-9907948-4-4
Medical Education In Cases Series | Volume 2 vi
About
The Medical Education In Cases (MEdIC) series puts difficult medical education cases under a
microscope. We post challenging hypothetical dilemmas, moderate discussions on potential
approaches, and recruit medical education experts to provide their insights. For further insight and
reference, curated comments from the medical community can be found alongside each case. These
cases and the commentaries were originally released via the Academic Life in Emergency Medicine
website (www.aliem.com), and are still available as single PDF downloads. The MEdIC team created
this ebook to promote easy access and use of medical education resources for our readers.
Since these materials were originally derived as part of the Free Open Access Meducation (FOAM, or
#FOAMed) movement, we are committed to distributing this resource as a free e-book.
Purpose
The MEdIC series is designed to encourage "guerilla" faculty development -- enticing and engaging
individuals who may not have time to attend faculty development workshops and think about
challenging cases in medical education.
Usage
This document is licensed for use under the creative commons selected license:
Attribution-NonCommercial-NoDerivs 3.0 Unported.
Where can I find this online?
The ALiEM MEdIC series can be found online at: www.aliem.com/medic/ We encourage you to come
check out the latest cases and get involved in our online discussions. Of note, each of the cases has
been made into an easily downloadable PDF that can be used as a classroom handout for your own
teaching or learning activities.
Medical Education In Cases Series | Volume 2 vii
Dedication
Medical Education In Cases Series | Volume 2 viii
I am a firm believer in case-based learning for medical students, residents, and my own faculty
development. Cases allow for cognitively realistic educational experiences. They help to create active
learning experiences by generating discussion. However, as any medical educator who has used cases
knows, the first challenge of case-based learning is finding a good case.
Good cases require solid educational objectives, sufficient detail and fidelity to allow the learner to
become immersed in the scenario, and various decision points to generate discussion. Finally, a good
case should spur the learner to decide upon a course of action that engages them to reconsider the
important aspects of the case. Finding cases to teach intrinsic competencies, such as how to be a
successful communicator or professional, is even more difficult than finding clinical cases. This is where
the Medical Education in Cases (MEdIC), Volume 2 fits perfectly.
Inspired by the Harvard Business Review cases and curated by a team of educators including Drs.
Teresa Chan, Brent Thoma, Tamara McColl, Sarah Luckett-Gatopoulos, Eve Purdy, and Michelle Lin, the
MEdIC Series has been putting difficult and original medical education situations under a microscope
since it began in 2013. This book is nicely designed. Every chapter starts with an interesting case that
highlights intrinsic competencies that most clinician-educators may struggle with and then continues
with the peer-reviewed point of view of two experienced clinicians (often experts in the field) who outline
two courses of action to help the learner with the final decision about the case. The intended audience
varies by case, but is inclusive of medical students, residents, faculty members, and other healthcare
professionals. These cases could easily be integrated into teaching sessions, ground rounds, and
faculty development initiatives. Using them in a flipped-classroom-style setting could drastically simplify
local teaching sessions directed at the development of intrinsic competencies. The best part is that this
book is available open access (i.e., free), at no cost to your learners.
Foreword
Medical Education In Cases Series | Volume 2 ix
This second volume continues in the heritage of the first. It succinctly presents challenging, real-world
scenarios, labeling them with CanMEDS and Accreditation Council for Graduate Medical Education
(ACGME) competencies, and ultimately provides a debriefing package that consists of both evidence-
based commentaries and helpful insights from the curated social media commentaries. Some
particularly compelling cases include a new look into a classic communication dilemma in “The Case of
Breaking Bad News Badly”! by Drs. Shreves and Shaw, a consideration of ethical and educational
principles during a possible outbreak scenario in “The Case of the Returning Traveler” by Drs. Tang and
Trueger, or a novel case on career decision making while considering the financial aspects of medicine
in “The Case of the Financial Fiasco”!by Drs. Garmel and Leap.
I hope you will enjoy reading this book and make sure to engage with the ALiEM MEdIC team online and
in their monthly case discussions.
Alireza Jalali, MD!
Teaching Chair, Faculty of Medicine, !
University of Ottawa
Medical Education In Cases Series | Volume 2 x
Evidence-based educational resources are difficult to develop. There are few teaching
resources that allow teachers to take their clinical experiences and easily translate them into
lessons on intrinsic, non-knowledge-based competencies.
Bearing that in mind, the MEdIC team has created a series that covers Medical Education
issues in a case-specific, problem-based format that allows educators and learners to
discuss important, frequently occurring dilemmas.
The Purpose of the MEdIC Series
We created the Medical Education in Cases (MEdIC) Series on the Academic Life in
Emergency Medicine (ALiEM) website, www.aliem.com, to teach physicians intrinsic
competencies for the Canadian CanMEDS and Accreditation Council for Graduate Medical
Education (ACGME) competencies. The intended audience varies by case but is inclusive of
medical students, residents, faculty members, and other healthcare professionals.
Every case in the series was shared with two experts identified as having relevant content-
expertise or experience. In a closed forum with the authorship team, the experts crafted
appropriate responses to the questions with references from relevant literature. Concurrently,
responses were solicited from the online community (predominantly made of healthcare
professionals) via social media platforms (Facebook, Twitter, Google+) and the ALiEM blog’s
comment board. Comments that were publicly available on Twitter and the ALiEM website
were analyzed by our authorship team using a qualitative methodology to create a curated
community commentary.
The expert and curated community responses were published one week after the case was
posted to the ALiEM website. Each case and its responses were reformatted as a teaching
package. We anticipate that MEdIC series resources can be used locally to spark a similarly
robust discussion. The supplemental expert and community commentaries can be used to
guide the debriefing process and direct further reading.
Preface
Medical Education In Cases Series | Volume 2 xi
In essence, we are galvanizing the community of practice
that has naturally evolved around the ALiEM website to
help create educational resources. The development of
these guides has proven that there is much to be gained
by crowd-sourcing information from a well-defined online
community, such as the ALiEM community. We have
created a series of cases that can be used to teach the
intended audience about naturalistic dilemmas commonly
faced by medical educators and learners. !Our hope is that
these resources will serve as springboards to discuss
difficult topics and introduce participants to literature that
may inform and change practice.
Purpose of this Resource
The purpose of this resource is to provide naturalistic case-
based scenarios that act as a springboard for discussing
difficult issues. Real life issues are complicated and guided
discussions are an excellent way to address difficult-to-
teach competencies. The intended objectives are listed for
each case.
Suggested Steps for Usage
1. Provide the case with questions prior to the session.
2. Refer participants to the questions during the session to
start the discussion.
3. Utilize the expert/community responses to assist in
debriefing the session.
4. Provide the expert/community responses along with the
references following the session.
The Conceptual Background
Physicians are often faced with situations that have no
easy answer. It is difficult to raise these issues for
discussion in a direct fashion and even harder to
determine evidence-informed responses since case details
are often tied to social contexts.
Practical Implementation Advice
We recommend that:
The case and questions are provided ahead of time
(approximately 1-3 days) so that participants can think
about the specifics of the case.
Time is given for small group or paired discussion (think-
pair-share) as well as a larger group discussion.!
At a sessions conclusion, participants should be
provided with the full handout (which includes the expert
response and curated community response).
About the Creation of this Resource
In the summer of 2013 a senior resident and a junior faculty
member sought answers for these dilemmas by (1) posing
them to physicians with substantial expertise and
experience and (2) posting them on an the ALiEM online
blog to crowd-source the wisdom of the masses. The
methodology for producing these resources was as
follows:
Original Derivation Workflow!
Phase 1: !Prior to posting the case to our website
!
Phase 2: After posting the case to our website
Medical Education In Cases Series | Volume 2 xii
Underlying Educational Theories
Conceptually, we utilized two key learning theories to
inform the derivation of our cases:
Naturalistic Decision Making!
The cases are based on real-life events that were
subsequently abstracted to key themes and then
'fictionalized' to preserve anonymity.! They are intentionally
complex and multi-dimensional so that participants can
explore each case's many aspects.! We attempted to
increase fidelity and facilitate naturalistic decision making
processes by using 'real life-like' scenarios. Our expert
responses represent the way that these scenarios are often
dealt with in the real world: by seeking out ‘eminence-
based’ advice from experienced mentors. To augment the
expert responses we crowd-sourced the answers by
opening the scenarios for comment on the ALiEM website.
Caveat: While our cases were fictionalized extensively to
protect learners’ identities, their true-to-life nature may
remind participants of events that have occurred to them or
their colleagues. Instructors should be sure to stress that
the cases are fictional.
Social Constructivism!
For these cases there are no ‘right answers’ but many
credible opinions.! Acknowledging this, we asked content
experts to both respond to our questions and developed a
new methodology informed by social constructivism.
1
Collaborative activities are useful for learning
2
and our
original online discussion provided diverse perspectives
that were analyzed to elicit key themes. In essence, we
gleaned the wisdom of the crowd during an online Problem
Based Learning session and constructed a shared
conclusion for a complex case. We feel that the theme-
based conclusions from the online session will be
invaluable in helping facilitators anticipate the issues and
debrief participants in live sessions.
Limitations
We have identified four main limitations:
Complexity of the Cases: The complexity of the cases
may require debriefing that stretches beyond what the
authors and instructors anticipated. Instructors should try
to anticipate additional issues that may come up in
discussion.! However, the inclusion of extensive crowd-
sourced discussion makes this unlikely.
Cultural Specificity: The participating experts and
community members come primarily from resource-rich
nations.! This may limit the cases’ generalizability to other
cultures.
English-Only Derivation: All of the content is in English
and no translated versions are available. The derivation
population for the community commentary was also
English-speaking.
Past Successes & Lessons Learned
Several of the MEdIC Series cases have been used to
facilitate large group activities. At Queen’s University
(Kingston, ON, Canada), one teacher has used this as a
pre-clerkship assessment to scaffold medical student’s
reflective abilities. By using a fictional case, Dr. Heather
Murray was able to both teach and assess the reflective
capacity of her second-year medical students, teaching
them about how to think about difficult situations they might
encounter in their future clinical learning environments.
!
Ideas for Improvement & Expansion
We are continually working to improve our MEdIC series
and invite those that have used this resource through to
respond to previous cases online and participate in future
discussions. (www.aliem.com/medic)!
If you used this book, we would love to hear how you used
our materials. Please email MEdIC@aliem.com.!
References
1. Swanwick, T. (2005). Informal learning in postgraduate medical
education: from cognitivism to ‘culturism’. Medical education, 39(8),
859-865.
2. Rasmussen A, Lewis M, White J. (2013). The application of wiki
technology in medical education. Medical teacher, 35(2), 109-114.
Medical Education In Cases Series | Volume 2 xiii
Chapter
1 The Case of the Backroom Blunder
Case
Expert Commentaries
Curated Community Commentary
2 The Case of the Debriefing Debacle
Case
Expert Commentaries
Curated Community Commentary
3 The Case of the Ebola Outbreak
Case
Expert Commentaries
Curated Community Commentary
4 The Case of the Late Letter
Case
Expert Commentaries
Curated Community Commentary
5 The Case of Breaking Bad News Badly
Case
Expert Commentaries
Curated Community Commentary
6 The Case of the Returning Traveller
Case
Expert Commentaries
Curated Community Commentary
7 The Case of the Financial Fiasco
Case
Expert Commentaries
Curated Community Commentary
8 The Case of the FOAM Faux Pas
Case
Expert Commentaries
Curated Community Commentary
9 The Case of the Flirtatious Patient
Case
Expert Commentaries
Curated Community Commentary
10 The Case of the Unseasoned Senior
Case
Expert Commentaries
Curated Community Commentary
Page
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Table of Contents
Medical Education In Cases Series | Volume 2 1
The Case of the
Backroom Blunder
1.
Describe the relationship between stress and humor.
2.
Describe the differences between slang and workplace-based lingo.
3.
List various slang terms used at your institution. Outline possible misinterpretations (i.e. how
patients or other non-healthcare practitioners might view these terms).
4.
Discuss the ramifications of using humor and slang in the workplace,
5.
Draw linkages between the following topics: humor, coping, resilience, compassion fatigue,
and burnout.
Intended Objectives of Case
Medical Education In Cases Series | Volume 2 2
By Heather Murray MD, MSc, FRCPC
Trevor, the 3rd year medical student rotating in the Emergency Department (ED), sat
down in the staff changing room to gather his thoughts. He had never seen a cardiac
arrest before, and this one had been a doozy. An elderly, obese man had come in by
EMS after suffering cardiac arrest from a huge lower GI bleed.
The ED team had run the arrest for a really long time, transfusing blood, IV fluids and
tons of drugs, intubating, bedside ultrasound, everything. The room had been a mess
when they finally called it. Trevor had gone with Dr. Elliott, the attending, to break the
news to the family. He had been impressed with her gentle compassion as she talked
with them.
Trevor was thinking about the code. He was pretty pleased with his CPR – he’d practiced
in the sim lab to get the timing and compression depth just right. Dr. Elliott had even
complimented him on it. He thought about the smell – melena, rectal bleeding, vomit…
it had been really awful. He hoped they could make the room smell better before the
family came in. They had been so upset. He thought about the rest of the code. It
seemed like Jeff, the senior resident, had struggled with the intubation. There had been
quite a scene at the head of the bed. Jeff had needed 3 extra suction catheters to deal
with all the airway vomit. Dr. Elliott had even asked if Jeff wanted her to take over. Trevor
thought that it should have been a bit smoother.
Trevor got up and left the change room. As he was about to come around the corner, he
overhead Dr. Elliott and Jeff talking. He stopped, not wanting to interrupt, but as he
listened he realized they were laughing together about the code! He heard them
making jokes about the smell and the rectal bleeding, calling the patient a “frequent
flyer” and talking about his “red underpants.” They didn’t seem to care at all that he had
died, or about how awful it had been. Jeff had screwed up the airway, Trevor was sure
of it. Shouldn’t he be apologizing to Dr. Elliott instead of laughing? Dr. Elliott had
seemed so nice and sympathetic to the family… was that all pretend? A fake show of
sympathy?! Now Trevor was angry.
After Dr. Elliott and Jeff went back into the ED, Trevor stayed in the back hall, fuming.
Sonia, another 3rd year student, arrived for her shift. When Trevor told her about Dr.
Elliott and Jeffs conversation, she pursed her lips and thought for a minute.
“Weird. Dr. Elliott always seems like she cares about people to me. Maybe it upset them,
too? Maybe they’re just blowing off steam?”
“No way. A caring doctor would never talk like that. And the slang? That’s just awful. That
man was somebody’s dad, and grandpa. I’m thinking of writing a complaint.
The Case of the Backroom Blunder
Medical Education In Cases Series | Volume 2 3
Competencies
ACGME
Professional Values (PROF1)
Patient-Centered Communication (ICS1) !
Accountability (PROF2)
CanMEDS
Professional!
Communicator
Questions for Discussion
1.
Medicine has a lot of slang – words that are specific to our particular culture, and sometimes
derogatory. Is there a role for this language? Should medical educators be held to a higher
standard?
2.
Black humor has been used as a coping strategy for stressful or traumatic events. Is this appropriate
in a patient-centered care world?
3.
How should physicians cope with stressful or horrifying situations? How do we ‘blow off steam’
effectively? How can we support our learners in stressful or horrifying situations?
Case
Dr. Heather Murray
Objectives:
Dr. Teresa Chan
Expert Responses
Dr. Brian Goldman!
Liz Crowe, MSW, PhD(c)
Curated Community
Commentary
Dr. Heather Murray!
Dr. Teresa Chan
Credits
Medical Education In Cases Series | Volume 2 4
If sticks and stones could break your bones…
The terms 'red underpants' and 'frequent flyer' are examples
of slang referred more formally by linguists as argot, which
is defined by the Merriam-Webster Dictionary as “an often
more or less secret vocabulary and idiom peculiar to a
particular group. The purpose of argot is to prevent
eavesdropping outsiders from understanding what you’re
talking about and to create a bond among colleagues,
teammates or friends. Medical argot is simply English
augmented with code words that are incomprehensible to
all but those in the know.
In general, argot or slang may be used to describe
undesirable or frustrating patients. An example used
commonly is ‘frequent flyer’, which refers to patients who
return again and again. Some use the term because they
believe the repeat patient is gaming the system for benefits
such as food, bandages and taxi chits.
There is little published evidence of medical argot. A 1993
survey of American physicians found that slang is learned in
the clinical setting and therefore uncommon until the third
or fourth year of medical school. That survey found that the
use of slang peaks during the first post-graduate year, and
begins to decline throughout the residency years. By 20
years of practice, admitted self-knowledge of slang terms
being only marginally higher than that of the preclinical
medical student.
1
In researching my book The Secret Language of Doctors, I
found a number of anecdotal collections of slang. While I
agree that residents are more likely to use argot, there is
evidence that slang is also used by some attending
physicians.
2
A 2012 study by Reddy and colleagues at the
University of Chicago found that 40.3% of hospitalists
surveyed admitted to making fun of other physicians, 35.1%
made fun of other attendings to colleagues, and 29.8%
admitted to making disparaging comments about a patient
on rounds.
2
Is there a role for this language?
If slang words are used, then, their use is proof that the
language serves a purpose.
Coombs and colleagues wrote that slang helps young
doctors overcome anxieties encountered during medical
training and practice those anxieties arising from clinical
and diagnostic uncertainty, the difficulty of treating fellow
human beings, and an attempt to distance oneself from
disease and death.
1
The anxiety associated with diagnostic and clinical
uncertainty doesnt get its due in common medical
discourse. In her brilliant book Experiment Perilous, Dr.
Renee Fox, one of Americas preeminent sociologists, wrote
at length about the challenge of dealing with therapeutic
uncertainty faced by physicians working in the 1950s at the
Medical Research Group in Boston.
What the physician can do to help a patient, then, is often
limited. What he ought to do is frequently not clear. And the
consequences of his clinical actions cannot always be
accurately predicted. Yet, in the face of these uncertainties and
limitations, the physician is expected to institute measures
which will facilitate the diagnosis and treatment of the problems
the patient presents.
3
Looking past the use of gender-exclusive pronouns, Fox
identified a core anxiety that is as pervasive today as it was
back then.
Terms like ‘social admission’ or dyscopia’ (i.e. ‘failure to
cope’) symbolize the helplessness perceived by residents
and attending physicians that a good deal of medical care
delivered these days is medically futile. Futility is often
discussed in hospital corridors because it is frequently
misunderstood by health professionals.
4
In the same vein,
the slang term frequent flyer calls attention to the growing
problem of readmissions and repeat visitors to the ED. In my
opinion, it is better to acknowledge evident problems in
health care than ignore them. The problem with the label
frequent flyer is that the term blames the patient, when
there’s a growing evidence that repeat visitors are system
failures that can be addressed.
5
Although argot may be useful to reduce physician and
trainee anxiety, there is no question that slang or argot is
often unprofessional.
6
The real issue is what to do when one
hears it. Acolytes of medical professionalism might argue
that slang should be called out and (if possible) stamped out
of hospital discourse. The problem with that strategy is that it
drives the use of slang underground.
Just because physicians no longer write odious terms such
as ‘FLK’ (funny looking kid) in medical charts does not prove
that the term is no longer spoken.
Slang and Medical Culture
By Brian Goldman MD, FACEP, MCFP(EM), FCFP
Expert Response
Medical Education In Cases Series | Volume 2 5
A better approach for medical educators is to notice the slang
and when heard to ask questions about the frustrations that
contribute to its use. Medical educators have a higher
obligation to model behavior that is respectful to patients,
colleagues and allied health professionals. Pejorative slang
tends to be learned avidly by residents and students when the
teacher is an attending physician.
Black Humor
Physicians have long used black humour to help cope with
anxiety provoking situations, as well as frustration at not being
able to cure or even help every patient. Experiment Perilous is
replete with examples of what Fox refers to a gallows humor.
3
There are many suggested purposes to gallows humor. Unlike
normal discourse with its many qualifiers and modifiers that
tend to soften the rhetorical blow gallows humor gets to the
truth in a hurry.
Gallows humor often mirrors power relationships. In medicine,
it’s considered acceptable for residents to joke about
attendings but not the other way around. In that context,
gallows humour regarding patients may reect the
powerlessness that physicians feel about treating patients who
cannot be helped by modern medicine.
In the past, gallows humour was regarded as therapeutic to
health professionals and even necessary to their well-being.
However, the rise of medical professionalism, has led to re-
evaluation and even condemnation of its use. As Katie Watson
wrote recently:
Critics of backstage gallows humour who are admirably concerned
with empathy for patients sometimes seem curiously devoid of
empathy for physicians. Medicine is an odd profession, in which we
ask ordinary people to act as if feces and vomit do not smell,
unusual bodies are not all that remarkable, and death is not
frightening.
7
To draw the line between appropriate gallows humor and
conduct unbecoming a physician, Watson suggests we think
about who is harmed by the joking. Jokes about defenseless
patients are off limits; jokes about doctors who are defenseless
or ineffective against death, decay, and chronic illness are not. If
the joke harms the patient’s access to decent care, that’s
verboten; so, too, is humor that diverts attention from structural
problems in the system by personifying them. Humor that
helps those on the front lines cope with oppressive situations is
okay, while humor that mirrors the relationship between bully
and victim is not.
How should this case be handled?
Slang and joking that enables physicians to open up about
difficult experiences can be therapeutic, while language that
cuts them off from their colleagues and themselves does not
serve the same purpose. I side with those who believe slang
and gallows humor constructed along the lines just
mentioned serve a therapeutic purpose without harming
patients. Used to cope with extraordinary situations such as the
one witnessed by Trevor, gallows humor may be in – in the
words of Watson a “psychic survival instinct.Such displays of
humor should take place far away from patients and families.
Trevors point of view is extremely valid. Were he to complain to
his supervisor or program director about the conversation he
overheard between the attending and the resident, there’s a
good chance the participants in that conversation would be
admonished for modelling unhelpful behaviour. Far better if
the next time, Trevor is included in the circle, where he can raise
his legitimate concerns, where his higher-ups could defend
their responses to the failed resuscitation, and where all three
of them could reflect upon what happened and how that
affected them.
References
1.
Coombs, RH, Chopra S, Schenk DR, Yutan E. (1993) Medical slang and
its functions. Social Science and Medicine. 36:987-98.
2.
Reddy ST, Iwaz JA, Didwania AK, O’Leary KJ, Anderson A, Humphrey HJ,
Farnan JM, Wayne DB, Arora VM. (2012) Participation in unprofessional
behaviors among hospitalists: a multicenter study. J Hosp Med,
7:543-50.
3.
Fox RC. (1998) Experiment Perilous. Physicians and Patients Facing the
Unknown. Transaction Publishers, New Brunswick, USA, page 238.
4.
Swetz KM, Burkle CM, Berge KH, Lanier WL. (2014) Ten common
questions (and their answers) on medical futility. Mayo Clin Proc;
89:943-59.
5.
Michelen W, Martinez J, Lee A, Wheeler DP. (2006) Reducing frequent
flyer emergency department visits. J Health Care Poor Underserved,
17(1 Suppl) 59-69.
6.
Husser WC. (2002) Medical professionalism in the new millennium: a
physician charter. Ann Intern Med,136:243-6.
7.
Watson K. (2011) Gallows humor in medicine. The Hastings Center
Report, 41:37-45.
Expert Response continued
About the Expert
!
Dr. Brian Goldman (@NightShiftMD) is an attending ED physician at Mount Sinai Hospital in Toronto and an Assistant
Professor at the University of Toronto. Since 2007, he has hosted White Coat, Black Art, the award-winning show on CBC
Radio One about modern medical culture. His TED talk Doctors Make Mistakes, Can We Talk About That?has been
seen more than 1 million times. He is the author of The Secret Language of Doctors, a bestselling book about hospital
slang and modern medical culture.
Medical Education In Cases Series | Volume 2 6
The use of humor, swearing and occupation specific language/
jargon to cope with dangerous, emotional and traumatic
settings is well documented amongst critical care workers.
1
Black or gallows humor was first identified as a phenomenon in
the World Wars
2
and is intellectualized as a type of humour that
arises in precarious, dangerous or confronting situations as a
means to manage negative emotions and consequences to
mental health and reduce stress.
3
According to various
studies
1,3-7
, humor in the critical care context has been identified
as a useful tool to:
Reduce tension, stress and anxiety;
Vent emotions;
Distance oneself from the intense emotions and the
confronting nature of the situation;
Re-interpret events and re-frame personal distress;
Distract from the horror and distress of the situation;
Ensure individuals continue to perform in the job;
Regroup personal resources;
Create a ‘psychological reset’ to ground people out of
their high adrenalin state;
Build bravado and strength amongst the team in times of
crisis;
Develop group cohesion;
Allow a sense of playfulness amongst the team;
Elicit social support;
Humor, swearing and crassness in critical care bonds
teams together forming a psychological defence system
against the work;
Provide a sense of group membership and identity that is
quite separate from the individuals’ behaviour in their
personal lives.
!
In this case, ensuring that Trevor understands the role that
humor plays in various environments may be of value. An
awareness of the use of humour in the critical care context
would allow individuals to view Dr. Elliott and Jeff’s behaviour
with a compassionate and understanding framework.
Norms & Expectations
Community expectations of the range of skills that critical care
professionals will possess are growing. We are all meant to be
skilled and clever clinicians who can make death an ‘option’; We
are also expected to be wonderful educators, counsellors and
communicators. Finally, we are asked to be able to absorb any
situation and mind our own self-care… all on top of our long
and often exhausting work schedules. These expectations are
unfair and unrealistic. Each one of these traits is a skill that needs
to be developed, nurtured and mentored over time. When we
have students of any occupation in our care it is wise to speak
with them early about the many strategies that people will use to
distance themselves and survive the often confronting, perverse
and tragic environment of critical care. Humor, swearing and
crass jargon are part of our ‘armor’ in surviving this work.
Providing orientation early for new staff and students can
prevent these folks from becoming disillusioned and feeling
isolated. For Trevor, this may have been particularly useful, since
it may prevent him from feeling isolated from his peers and
mentors.
Humor can be an adaptation to stressors or social phenomenon
for members of the emergency services, but it has also been
used by those who work in defense forces, funeral homes and
even the sex industry. Humor is often used to incorporate new
members to the team. Jokes and stories may be used to
educate and orientate new members in a way that is jovial
though builds realistic expectations and warns of the work and
chaos that will ensue.
7
Humor as an Adaptive Strategy
The nature and culture of the critical care environment means
clinicians will often find themselves unable to situate themselves
easily on the continuum between empathy and detachment.
8
Context specific variables (mood, previous experiences,
personal attachments) will force clinicians to change their
location within this spectrum. They will slide up and down this
empathy-detachment continuum. At times they will be deeply
empathic and connected to patients, families and situations, and
then at other times they might detach and distance themselves
from the event by using humor and crass language to protect
themselves from emotions. At times, this detachment will be
adaptive, in that it may allow the provider to move quickly onto
the next patient and situation as is the requirement of our work.
This is a skill that Dr. Elliott has clearly mastered; He is an
empathetic and connected attending with his patients; but then
adaptively laughs and reframes the situation with colleagues in
the backroom.
Similar to our medical student Trevor, people new or external to
the critical care context may be easily offended and shocked by
the humour used amongst workers with little understanding as
to the pressures and tragedy of the job. However, it appears that
those who want to survive emotionally, the critical care
environment will need to share a sense of the absurd and enjoy
humor as part of the job in the way that Dr. Elliott and Jeff are
doing after what was obviously a gruesome and confronting
event.
9
We don’t cry in critical care, we tend to laugh and joke and be sarcastic…Why?
by Liz Crowe BSW, PhD (candidate)
Expert Response
Medical Education In Cases Series | Volume 2 7
About the Expert
Liz Crowe is an Advanced Clinician Pediatric Social Worker who has worked extensively with children and families impacted
by grief, loss, trauma, crisis and bereavement since 1995. She currently works as an Advanced Clinician Social Worker at the
Brisbane Mater Children’s Paediatric Intensive Care Unit and as a Program Facilitator at Griffith University researching the
use of Advance Care Planning. She is a currently doing a doctorate exploring Staff Wellbeing in the Pediatric Intensive Care
Unit with an aim to developing formalized interventions and education programs for critical care health professionals,
including communication skills for health professionals and teams to ensure optimal outcomes for staff and families. She is
the successful author of The Little Book of Loss and Grief You Can Read While You Cry. Liz is a passionate and humorous
educator who can captivate audiences on a range of subjects.
References:
1.
Roe, A and Regehr, C (2010) ‘Whatever Gets You Through Today: An
Examination of Cynical Humor Among Emergency Service
Professionals’, Journal of Loss and Trauma, 15:448–464.
2.
Frankyl, V. (2006) ‘Man's search for meaning’, Beacon Press, Boston:
Mass.
3.
Scott, Tricia (2007) ‘Expression of humour by emergency personnel
involved in sudden deathwork’, Mortality, 12(4): 350-364.
4.
Burchiel, R.N, and King, C.A. (1999) Incorporating fun into the
business of serious work: the use of humor in group process;
Seminars in Perioperative Nursing, 8(2): 60-70.
5.
Moran, C and Massam, M. (1997) An evaluation of humour in
emergency work’, Australasian Journal of Disaster and Trauma Studies,
3:10.
6.
Olsson H, Backe H, Sorenson S, Kock M (2002) The essence of
humour and its effects and functions: a qualitative study’ Journal of
Nursing Management, 10:21-26.
7.
Sanders, T. (2004) Controllable Laughter: Managing Sex Work
Through Humor’’, Sociology : the Journal of the British Sociological
Association, 38(2): 273.
8.
Jellinek, M. S, Todres, I. D, Catlin, E. A, Cassem, E. H., Salzman, A.
(1993) Pediatric intensive care training: confronting the dark side,
Critical Care Medicine, 21(5):775-779.
9.
van Wormer, K. and Boes, M. (1997) ‘Humor in the emergency room: a
social work perspective’, Health & Social Work, 22(2): 87-92.
Expert Response continued
Medical Education In Cases Series | Volume 2 8
There was a huge online response to this case, and a rich
and nuanced discussion occurred, both in the blog
comments section and on Twitter. A number of themes
emerged, which are summarized below. In this summary we
aimed to highlight issues that are particularly important for
practitioners in the emergency department (ED), but the
blog comments host a wide breadth of information that is
applicable to nearly all healthcare professionals.
The Use of Slang
Medical slang use was discussed extensively and a few
differing perspectives emerged. There seemed to be
general agreement that slang that is explicitly derogatory
towards patients is inappropriate. However, there were
differing perspectives about exactly which terms are
‘inappropriate’.
Some commenters felt that any slang language in health
care is derogatory and as Dr. Michelle Gibson stated:
“reveals how people really feel about patients. Others
emphasized how language can perpetuate stereotypes or
misconceptions, implicitly endorsing certain elements of the
healthcare culture.
Jon Bennetson stated that he was appalled by the use of
medical slang:
What's shocking to me is that this kind of patient-denigrating
language is seen as so professionally acceptable by doctors
that it routinely appears in their publications and medical
magazines and no doctors complain about this language.
Specifically he referred to general practice trade journals
that use medical slang in their publications.
Others felt that it is not the terms themselves but the intent
and tone used that determines the attitude of the physician
or care provider. Carolyn Thomas admitted that she has
experienced depersonalization as a patient in the hospital
setting. However, the slang in the case did not bother her
but instead she found the laughter of the caregivers
offensive: “High hilarity over a patient's rectal bleeding
should be as chilling an observation to health care providers
as it feels to me.!
Slang terms, however, can be used to convey messages
between providers. As Teresa Chan noted, medical slang
may parcel information for efficient communication. Loice
Swisher agreed:
Knowing a person is a ‘frequent flyer’ tells me that I likely have
information available from prior visits as to what has been tried,
tested and offered. It may give me a clue that being the 6th
doctor to see a patient with unexplained abdominal pain that I
might not be able to provide an answer and that I need to help
the patient get on a new path out of the ED revolving door. It
could mean that there are underlying social or financial issues
that might have some assistance available…. That doesn’t mean I
think less of the patient as a person.
One of the other hazards of using such terms is that it can
affect your decision making. Anand Swaminathan cautioned
that the term ‘frequent flyer’ may lead to premature closure
and compromise diagnostic reasoning. Similarly, some
debated the use of the term ‘dyscopia or ‘failure to cope’,
highlighting that this can similarly lead to premature closure
around a patient’s particular scenario, as has been
suggested previously in the literature.
1
Black humor: !
A coping mechanism for stress and trauma
Most commenters agreed that both slang and black humor
are methods of creating emotional distance’ from difficult
scenarios, which necessarily depersonalize the patient.
Participants were split about the merit of this particular
coping technique.
Many of the emergency physician commenters pointed out
that in the rapid paced ED, the ability to emotionally switch
from one patient to another is a survival skill.
As Anne Marie Cunningham stated:
…the strongest theme emerging from the discussion is that
black humour/derogatory language is not a sign of not caring,
but a sign that doctors are under pressure. Can they be given
time and space for better ways of coping? That seems to be the
challenge.
Kate Bowles shared her experience as a patient:
From my experience and discussion with other patients, we also
hide the humour a bit around staff. There's a kind of illness
professionalism in patients too, weirdly. There isn't an answer to
this; I'm just suggesting that maybe there's some black humour
being used to cope on both sides, that mutual professional
courtesy keeps apart.
Meanwhile, Jon Mendel wrote that he believed power
dynamics within a relationship determines the acceptability’
of the use of black humor or slang (i.e. black humour may
be fine for patients to use, but not for their doctors).
By Heather Murray MD, MS, FRCPC and Teresa Chan MD, FRCPC, MHPE(candidate)!
A qualitative methodology was used to curate the community discussion. Tweets and blog comments were analyzed, and four
overarching themes were extracted from the online discussions.
Curated Community Commentary
Medical Education In Cases Series | Volume 2 9
Table 1 (below) discusses a selection of the pros / cons of
medical practitioners using black humor as a coping
strategy.
NB: For more on Gallows humor, this article by Elizabeth
Sullivan in the Psychologist magazine was a suggested
reference.
Learners & Black Humor
This case also highlighted the importance of incorporating
learners into the discussions around black humor.
Loice Swisher suggested that perhaps what Trevor
witnessed was a very unique EM skill set that he was not
accustomed to seeing: Emotional Shapeshifting. Swisher
goes on to explain this phenomenon as follows:
We are trained to rapidly change for one situation to another
while making every attempt to have our demeanor match the
need. When one observes this shifting to find where the other
person is, well, it can be confusing and seem deceiving.
Similarly, Liz Crowe observed that "immediate compartment-
alization of emotions may be a necessary strategy required
of a busy emergency physician so that they can stay sharp,
complete their shift and take care of the many other ED
patients requiring assistance."
In the following quote, Stella Yiu eloquently described the
insidious nature of how teachers might not be fully self-
aware of our practices in this regard, and how this might
affect our teaching around such cases:
It might be such a gradual process and not so explicit to
ourselves …that we never see it as such and therefore do not
explain it to our learners. We have all thought about patients
and cases long after the shift has ended when the full impact of
‘who’ they are hit us - and the learners clearly do not see this (or
do not have this explained to them later).
One medical student (Eve Purdy) stated: …it is desperately
uncomfortable when you see superiors making light of a
situation that has really shook you. It slams any door shut to
debriefing. Her sentiments are echoed by those previously
reported in the literature.
2
Medical students have been
shown in previous studies to be a very idealistic bunch that
desire to be physicians who are able to maintain empathy,
ethics and honesty.
3
Encounters such as Trevor’s may lead to
dramatic changes in their perception.
Many participants thoughtfully articulated the treacherous
slippery slope that black humor can open up, especially
when learners are involved. One brave resident (Sarah
Luckett-Gatopoulos) even noted that as she has journeyed
up the ranks in medical education she finds herself using
terms that she might have found alarming as a medical
student. This maps with findings from the nursing literature.
Pro
Con
Anand Swaminathan: “Black humor is important in all fields of medicine
and particularly in EM. We see the worst that society has to offer on a
regular basis. We see terrible things happen to good (and bad) people
every day. I think depersonalization is critical for us to keep our sanity.
Stella Yiu: We gradually built our armor of coping/defense
mechanisms for our hectic daily work. I would even go further and
suggest that sometimes when the situations are dire, we ‘need’ to
depersonalize so we can focus on tasks and decision-making
objectively rather than being swept up in emotions. I think that
mechanism of separating illness from the person works well (for say, a
pediatric code, a disaster etc.) that we started using it for other patients
as well.
Liz Crowe: “Cruel and inappropriate humor may not always be
immature coping mechanisms. However they are often only first line of
defense - coping mechanisms that allow individuals to continue with
several hours of difficult and busy shifts that lay ahead. However, for
many they will then need to unpack their emotions, review their
intentions and work through their emotions and experience of the
event. We are all really different.
Jordan Grumet: “Ultimately, I found that gallows humor and slang were
immature coping mechanisms, Becoming cruel and callous would neither
shield me from the pain or save me from my own failings…We currently
face a most difficult period in medicine. Burn out is at an all time high, and
physician suicide is the topic gracing the pages of our most prominent
periodicals. Our coping mechanisms are not working. We must stop
making our patients the butt of our grisly humor.”
Carolyn Thomas: “Some may blow this (laughter) off as merely stress-
releasing, as if it were somehow effective, instead of what it actually is: a
symptom of depersonalization that is ultimately the slippery slope to
career burnout.”
Amy Price: “Dark humor does not help long-term and it short circuits
ways of coping and re-framing and real support through the dark times
when we give our all and the effort is death or destruction.”
John Cosgrove: “…many are themselves uncomfortable with hearing
black humor and associated derogatory language and believe it to be
immature and indicative of lack of caring.”
Table 1 The pros / cons of medical practitioners using Black Humour as a coping strategy.
Curated Community Commentary continued
Medical Education In Cases Series | Volume 2 10
Indeed, medical educators and clinical teachers alike need
to be cognizant of the impact on the development of
medical students. Role modeling may be the most potent of
teaching strategies, especially in the workplace.
4
As
Jonathon Tomlinson highlighted:
“Behaviour is contagious…the importance of role modeling is
probably beyond dispute. We learn ways of coping from our
peers, gallows humour[sic] is one of several ways we cope, but
it is a problem if it is the predominant or only way of coping
because it is very unlikely to be suitable or sufficient for all the
members of a team.
Participants all seemed to concur that the hidden curriculum
may manifest in these scenarios, and if not properly
addressed (or debriefed) may lead to changes in learner
behaviour.
5,6
A Call To Action:
Finding alternative strategies for fostering resilience
Studies have shown that emergency medicine trainees are
frontline workers that may be particularly susceptible to the
stresses of providing clinical care.
7
Time available for debriefing in the ED was explicitly
identified as a challenge. Bearing this in mind, participants
did make numerous suggestions for how we might better
foster resilience in healthcare providers. This is a particularly
salient issue since there are increasingly high profile
instances of post-traumatic stress disorder (PTSD),
compassion fatigue leading to burn out and suicide in our
healthcare colleagues.
Discussion participants agreed that there is very little formal
and informal training in debriefing critical events. Loice
Swisher linked a paper which showed that 88% of Pediatric
EM fellows have no debriefing training, despite the majority
(90%) wanting to access it.
8
Amy Price and Liz Crowe both
advocate for more in depth training at all levels in grief
management and resilience. Jonathon Tomlinson, like other
writers before
9,10
, suggested there might also be further
opportunities for training in professionalism education:
Instead of telling doctors and students how they (should)
behave we should advocate for humane working conditions and
make time for all healthcare professionals to discuss their work
through peer supervision, (like the Schwartz rounds other have
mentioned) and in ways that give a wider range of opportunities
to cope.
Jonathon Tomlinson points out some studies which support
alternate methods for professionalism education including
Launer’s narrative-based supervision
11
and Greenhalgh’s
educating for complexity.
12
He also highlighted the
University of Westminster’s Compassion and Resilience in
the NHS series.
13
Meanwhile, there may also be a role for expanding the
training to include the practice of empathy in the clinical
setting,
14
since previous studies have shown that clinical
exposure alone is not sufficient.
15
All these issues must be kept in mind as we go forward in
designing curriculae for our learners. Of note, the origins of
cynicism and emotional distance may begin as early as the
first clinical exposure for some (i.e. usually third year of
medical school).
16
References
1.
Granger, K., Ninan, S., & Stopford, E. (2012). The patient presenting
with'Acopia'."Acute medicine,"12(3), 173-177.
2.
Wear, D., Aultman, J. M., Zarconi, J., & Varley, J. D. (2009).
Derogatory and cynical humour directed towards patients: views of
residents and attending doctors."Medical education,"43(1), 34-41.
3.
Hurwitz, S., Kelly, B., Powis, D., Smyth, R., & Lewin, T. (2013). The
desirable qualities of future doctors-A study of medical student
perceptions."Medical teacher,"35(7), e1332-e1339.
4.
Cruess, S. R., Cruess, R. L., & Steinert, Y. (2008). Role modelling—
making the most of a powerful teaching strategy." BMJ." 336(7646),
718-721.
5.
Hendelman, W., & Byszewski, A. (2014). Formation of medical
stude nt pro fe ss io na l i de nt it y: categorizing lapses of
professionalism, and the learning environment." BMC medical
education,"14(1), 139.
6.
Kowalczyk L. Empathy gap in medical students. The Boston Globe.
March 25, 2013. Accessed on October 1, 2014. Available at: http://
goo.gl/IcAGBm.
7.
Mills, L. D., & Mills, T. J. (2005). Symptoms of post-traumatic stress
disorder among emergency medicine residents." The Journal of
emergency medicine,28(1), 1-4.
8.
Staple, L. E., O'Connell, K. J., Mullan, P. C., Ryan, L. M., & Wratney, A.
T. (2014). National Survey of Pediatric Emergency Medicine Fellows
on Debriefing After Medical Resuscitations." Pediatric emergency
care.
9.
Huddle, T. S. (2005). Viewpoint: Teaching Professionalism: Is Medical
Morality a Competency?."Academic Medicine,"80(10), 885-891.
10.
Sulmasy, D. P. (2000). Should medical schools be schools for
virtue?."Journal of general internal medicine,"15(7), 514-516.
11.
Gill, D., Griffin, A., & Launer, J. (2014). Fostering professionalism
a m o n g d o c t o r s : t h e r o l e o f w o r k p l a c e d i s c u s s i o n
groups."Postgraduate medical journal,90(1068), 565-570.
12.
Greenhalgh. Fraser, S. W., & Greenhalgh, T. (2001). Coping with
complexity: educating for capability."BMJ,"323(7316), 799-803.
Curated Community Commentary continued
Medical Education In Cases Series | Volume 2 11
Bennetson
Kate Bowles
Deidre Bonnycastle
(@Bonnycastle)
Teresa Chan (@TChanMD)*
John Cosgrove
Anne-Marie Cunningham
(@amcunningham)*
Liz Crowe (@LizCrowe2)*
Michelle
Gibson(@MCG_MedEd)*
Jordan Grumet
(@jordangrumet)*
Carolyn Hastie
S. Luckett-Gatopoulos*
(@SLuckettG)
Shannon McNamara
Jon Mendel* (@JonMendel)
Heather Murray*
(@HeatherM211)
Eve Purdy* (@Purdy_Eve)
Amy Price
Anand Swaminathan*
(@EMSwami)
Loice Swisher
Carolyn Thomas*
(@HeartSisters)
Jonathon Tomlinson*
(@mellojonny)
Deborah Verran*
(@VerranDeborah)
Stella Yiu
Aliases
Gourmet Penguin
Stehoscope Nunchucks
As well as several other guests
who commented anonymously.
Tweeters
@Betabetic
Charles Alpren (@ChazzaiA)
Julia McKenzie (@turquoisejulia)
Ross Morton (@SignInDoc)
Km Boehm (@kmboehm1)
Contributors
Thanks to the participants (in alphabetical order) for
all of their input:
13.
University of Westminster’s Compassion and Resilience in the NHS
series. Available at: http://www.westminster.ac.uk/resilience/news/
compassion-and-resilience-in-the-nhs-lecture-series.
14.
Afghan, B., Besimanto, S., Amin, A., & Shapiro, J. (2011). Medical
students' perspectives on clinical empathy training." Education for
Health,"24(1), 544.
15.
Blumberg, P., & Mellis, L. P. (1985). Medical students' attitudes
toward the obese and the morbidly obese." International Journal of
Eating Disorders,"4(2), 169-175.
16.
Eikeland, H. L., Ørnes, K., Finset, A., & Pedersen, R. (2014). The
physician’s role and empathy–a qualitative study of third year
medical students."BMC medical education,"14(1), 165.
Resources suggested during this discussion
1.
EMCases Episode 49, Effective Patient Communication, Patient
Centered Care & Satisfaction.
2.
Maben, J., Latter, S., & Clark, J. M. (2007). The sustainability of ideals,
values and the nursing mandate: evidence from a longitudinal
qualitative study.Nursing Inquiry,"14(2), 99-113.
3.
Attitudes and Habits of Highly Humanistic Physicians
4.
Launer J. Conversations inviting change.
5.
Schwartz Centre Rounds
6.
Webster F, Rice K, Dainty KN, Zwarenstein M, Durant S, Kuper A.
Failure to Cope: The Hidden Curriculum of Emergency Department
Wait Times and the Implications for Clinical Training. Academic
Medicine. Online first September 30, 2014. doi: 10.1097/ACM.
0000000000000499
7.
Dekker S. Just Culture. http://www.youtube.com/watch?
v=t81sDiYjKUk&feature=youtu.be
8.
Maben J. Care, Compassion and ideals: Nurses’ experience of
nursing. http://www.youtube.com/watch?
v=0zR7gJo5fak&feature=youtu.be
9.
University of Westminster’s Compassion and Resilience in the NHS
series. http://www.westminster.ac.uk/resilience/news/compassion-
and-resilience-in-the-nhs-lecture-series
Curated Community Commentary continued
Resources that were authored by
participants in this discussion:
Anne Marie Cunningham
Social Media, Black Humour, and Professionals
Jonathon Tomlinson
Do Doctors need to be Kind?
Doctors and Empathy
Stella Yiu
Loss of Innocence
Liz Crowe
Swearing your way out a crisis (by Chris Nickson; the podcast on
the page is by Liz)
Medical Education In Cases Series | Volume 2 12
The Case of the
Debriefing Debacle
1.
Describe a framework for debriefing.
2.
List and describe various types of debriefing activities.
3.
Discuss the concept of the ‘second victim’.
4.
Elucidate linkages between the following topics: post-traumatic stress disorder,
debriefing, compassion fatigue, and burnout.
Intended Objectives of Case
Medical Education In Cases Series | Volume 2 13
By Joanna Bostwick MD, CCFP(EM)
"Excuse me Dr. Berner. One of the nurses came to ask me if we were aware that there is
a 20 year old guy in Resusc with a heart rate of 200,said Melanie nervously. Melanie, a
third year medical student, had just started her Emergency Medicine (EM) rotation.
"What!?! I didn't hear about that. Let's go over right away."
Dr. Berner sprinted ahead as Melanie grabbed her stethoscope. As Dr. Berner entered
the Resuscitation Bay he saw a young slender male who did not appear well with
vomitus running down his cheek. He looked sonorous and diaphoretic and the monitor
showed a heart rate now of 220 beats per minute. Two nurses were hard at work
attempting to establish an IV and draw bloodwork
"Can anyone tell me about this patient?” Dr Berner demanded.
"He was found slumped over at a house party tonight. The paramedics think he took a
cocktail of drugs and alcohol," said one of the senior nurses while she primed an IV with
normal saline.
Dr. Berner turned to Melanie, "Have you ever intubated before?”
"Ummmm....A few times? But I'm not even sure what's going on here" Melanie
stuttered. She had intubated a couple of times in the OR but never in the ER.
“We can talk more about what's going on in a moment, first we need to secure the
patient’s airway."
"The O2 sats are starting to drop and I can't wake him up," said a nurse anxiously.
"Ok team, lets give the naloxone and get set up to intubate.
“The naloxone was given per protocol by EMS with no effect earlier,stated the charge
nurse.
Alright then, I'm going to intubate right now." Let's get the crash cart at the bedside
and page RT stat." Dr. Berner turned to Melanie, "I will have you watch this one and you
can attempt the next intubation.
The patient was intubated successfully and Dr. Berner sighed with relief. With the
patient’s airway secure, his oxygenation improved. Dr. Berner now turned to Melanie to
ask about toxins that could cause tachycardia when suddenly the monitor started to
beep as Dr. Berner looked in horror to see ventricular fibrillation.
The Case of the Debriefing Debacle
Medical Education In Cases Series | Volume 2 14
"Melanie start chest compressions,ordered Dr. Berner, “Betty, can you give 1 mg of
epi? Also, Sarah can you go get Dr. Takeda and his residents over in the Quick Care
area?”
Melanie had never done CPR before in real life and shuddered in horror as she felt
ribs breaking beneath her hands.
Her head was spinning. What had just happened? She was beginning to feel her arms
fatiguing and didn't know how she could keep this up.
There was a fury of people who suddenly appeared to help at the bedside.
“Ok stop CPR let's check the rhythm and pulse,” said Dr.Berner.
"Asystole,” said several in unison.
“Resume CPR,Dr Berner said and then turned to Melanie, “you can switch off with
Joe. He’s right behind you, ready to take over CPR."
"Dr.Berner the family has arrived they would like to find out what's happening and
want to see their son," said the social worker quietly from the doorway. “I have tried
to prepare them for what they are about to see."
Dr. Berner nodded his assent, and the social worker disappeared momentarily. A few
minutes later, she returned with a middle-aged couple, both clinging to her for
support.
Another round of Epi please, Betty?”
"How long has the code been going on?” asked Dr. Takeda as he arrived. He and Dr.
Berner turned to each other to discuss the proceedings on the code, just out of
Melanie’s earshot. Dr. Takeda then went over to talk to the parents of the patient,
talking to them somberly for several moments.
A few moments later, the couple looked to him and said: “Please stop.
Dr. Takeda then nodded at Joe, who had the bedside ultrasound set up, and ready to
use at the next rhythm check.
“Rhythm and pulse check please,” ordered Dr. Takeda.
“No pulse… Asystole…
"Bedside echo shows no cardiac activity.
“Let's call the code,” sighed Dr. Berner. “Time of death…
There was a large wail as the patient’s mother fell to the ground. Melanie tried to hold
back her own tears.
For the next few minutes, Melanie felt like she was walking through a daze. Had that
really just happened? She felt like it had just been a few minutes since she had seen
him arrive with the paramedics! He had groaned when she tried to do a sternal rub…
He had been alive. What had happened? Maybe her compressions weren't forceful
enough? What if it was her fault?
Medical Education In Cases Series | Volume 2 15
Competencies
ACGME
Professional Values (PROF1)
Patient-Centered Communication (ICS1) !
Team Management (ICS2)
CanMEDS
Professional!
Communicator!
Collaborator
Questions for Discussion
1.
How do you debrief this case with Melanie?
2.
How do you address her fears that she did something wrong?
3.
What is a general approach to debriefing a medical student after a bad outcome in a young patient?
4.
What is the role of the family’s presence during a resuscitation?
Case
Dr. Joanna Bostwick
Objectives:
Dr. Teresa Chan
Expert Responses
Dr. Hans Rosenberg!
Dr. Tessa Davis
Online Community Moderators
Dr. S. Luckett-Gatopoulos!
Eve Purdy
Curated Community
Commentary
Dr. Teresa Chan
Credits
Medical Education In Cases Series | Volume 2 16
In the field of Emergency Medicine most of us would have
encountered a similar experience as that of Melanie. Our
work can often seem like the routine intermixed with
moments of chaos that can leave us in a fragile emotional
and psychological state. A case such as the one described is
capable of doing just that. As an attending/supervising
physician there is a clear role in this case for debriefing with
our learner. I’ll briefly discuss a suggested approach to
debriefing and how it could play out in real life.
Debriefing is an integral process in learning which allows for
discussion and analysis of an experience, evaluating and
integrating lessons learned into ones cognition and
consciousness.
1
The debriefing approach that I prefer to use is a be a 3-step
approach described by experts from The Center for Medical
Simulation in Cambridge, Massachusetts
2
:
Step 1 – The reactions phase
At this point it would be important to allow Melanie, as well
as any other participants in the case who would also like to
participate, to be able to “blow offsome steam and let out
their emotions about the case. In our particular scenario
there appears to be a mix of shock, sadness and perhaps
feelings of inadequacy. This is the time to “normalize” both
the emotions that Melanie is experiencing, as well as the
case that she had just seen. If applicable, this would be the
time when the supervisor can share a similar experience
they had at some point in their training as part of the
normalization process. Additionally, the facts of the case
should be explicitly reviewed at this time.
Step 2 – The understanding phase
This step is when Melanie would be given the opportunity to
describe her frame of mind, how that led to a certain action
and what the results were. For example, Melanie may
mention that although she had previous knowledge of how
to perform Cardio-Pulmonary Resuscitation (CPR) she had
never performed it on a person. The resulting sensation of
ribs fracturing under her hands led to a distinctly negative
experience and did not yield the results she may have
hoped for or expected (i.e. successful return of spontaneous
circulation). This is also a time when the debriefer would
make explicit whats on their mind in order to clarify certain
points and encourage discussion. In our case, a statement
such as: “I was pleased to see that you had excellent
technique during your performance of CPR, it was at the
appropriate rate of 100 beats per minute and the ideal
depth. This has a two-fold effect of letting Melanie know
what she did correctly and the rationale behind it.
Step 3 – The summary phase
At this final step, it is time to allow Melanie to tell the
debriefer what she thought she did well, what she would do
differently and how she might implement it in the future. It is
a simple, but often overlooked skill to be able to reflect on
actions and make a plan which then can be acted upon if a
similar scenario were to arise.
This approach would be helpful in dealing with a learner
such as Melanie after being exposed to what can be a very
traumatic experience. However, that should not be the end
of the discussion. It would also be important to gently
remind her what a profound effect these types of cases can
have on health workers and that she is not alone. There is
clear evidence that exposure to critical incidents is
associated with post-traumatic stress symptoms, anxiety and
depression.
3
As such, it would be wise to ensure that there
can be some follow up in the near future to see how Melanie
is doing. It doesn’t have to be formal, but support from
colleagues/supervisors can have a protective effect when it
comes to the negative outcomes associated with critical
incidents.
4
References
1.
Lederman LC. Debriefing: towards a systematic assessment of theory and
practice. Simulations Games. 1992;23(2):145–160.
2.
Gardner R. Introduction to debriefing. Seminars in Perinatology. Elsevier;
2013 Jun 1;37(3):166–74.
3.
de Boer JC, Lok A, Verlaat EV, Duivenvoorden HJ, Bakker AB, Smit BJ.
Social Science & Medicine. Social Science & Medicine. Elsevier Ltd; 2011
Jul 1;73(2):316–26.
4.
Adriaenssens J, de Gucht V, Maes S. International Journal of Nursing
Studies. International Journal of Nursing Studies. Elsevier Ltd; 2012 Nov
1;49(11):1411–22.
3 Steps for a Smooth Debriefing
by Hans Rosenberg MD, CCFP(EM)
Expert Response
About the Expert
!
Dr. Hans Rosenberg (@hrosenberg33) is an Emergency Physician in Ottawa, ON, Canada. He is an Assistant
Professor, and the IT director of the University of Ottawa’s Department of Emergency Medicine. He is a contributor
to EM:RAP. His interests are in medical education and web 2.0 tech.
Medical Education In Cases Series | Volume 2 17
This is an emotional and difficult situation whether you have
been working in medicine for 2 days, 2 years, or 2 decades.
However, as a medical student Melanie is in a particularly
vulnerable position because she has no previous experience or
preparation.
A debrief is needed to allow staff to feel comfortable opening
up about their reflections. This might include practical points
such as finding a private area to debrief; making sure all the staff
have space to sit and are facing each other; and noting that
everyone in the team is a valuable contributor.
1
Debriefing Models
There are several models for debriefing. The most common is
the Critical Incident Stress Debriefing (CISD) model, created by
Mitchell (1983)
2
and elaborated on by Dyregrov (1997)
3
, which
includes 7 stages:
Others include Kinchin’s emotional decompression model
4
,
which uses a diving analogy (the stages are diving in; deep
water; middle water; breaking the surface; and treading water)
and the SHARP medical model (5 stages: Set learning
objectives; How did it go; Address concerns; Review learning
points; Plan ahead).
5
The General Concepts
All of the above models (and there are plenty more) encompass
the same key points:
1. Establish the facts
Outline what happened with this patient, the medical elements
of the resuscitation, and how the case progressed. Often in
times of high stress, the facts can get blurry in our minds. Stating
the facts out loud at an early stage can help provide an accurate
memory of the situation.
2. Address thoughts and feelings
It is important to discuss people’s thoughts and worries. This
medical student is having the same reaction we all do when
faced with death: Did we do something wrong? Could we have
done something differently that would have led to a different
outcome?
Often, a specific element of the resuscitation can become the
focus. A senior doctor may worry about his intubation skills and
if he could have been faster; a junior doctor may worry about
the time taken to recognize how unwell the patient was; a
medical student may worry that she wasn’t doing the CPR
correctly and that her fatigue brought about the patient’s death.
It would be more helpful for Melanie to be allowed to discuss
her specific worries openly as opposed to being dismissive (i.e.
waving her, saying “You didn’t do anything wrong”). Asking what
her concerns are, and perhaps even discussing the role she
played throughout the resuscitation, will help her to
decompress.
3. Discussing our own symptoms
I think we all have a patient that suddenly flashes into our mind
in the middle of the night, or even in the most unexpected
situations. That’s a normal part of being human and coping with
our day-to-day working lives. However, if these thoughts or
feelings are affecting our work, sleep or personal life then they
may need some additional support. Post-traumatic stress
disorder is described in healthcare professionals after
witnessing stressful events and the healthcare team needs to be
vigilant to the signs and symptoms.
Be cognizant of humanity and grief. ED staff have a tendency to
wave off emotional experiences, many finding it challenging to
confront emotions during debriefs. However, there is clear
evidence of the psychological effects of resuscitations on
doctors
6
, so its essential to acknowledge this.
Debriefing models
by Tessa Davis MBChB, MA, FACEM
Expert Response
Stage
Description
Introduction
Introduce the team members, set out some guideline
for the debriefing conduct
Facts
A very brief overview of the facts
Thoughts
“What was your first thought?”
Reactions
Aiming to transition from ‘thoughts’ to ‘symptoms’ by
asking “what is the worst thing about this for you
personally?”
Symptoms
Team members listen to other people’s emotional or
physical symptoms and contribute theirs
Teaching
Normalizing symptoms, explaining reactions, teach
about stress management and any topic relevant to
the specific case
Re-entry
An opportunity for any other questions or statements.
The team summarises the discussion.
Medical Education In Cases Series | Volume 2 18
4. Learning from our mistakes
As doctors we are always learning from our patients we can
always do better next time and identify learning points.
Resuscitation scenarios can often highlight systemic flaws in the
department: equipment that is not available or complete;
problems with drug access; or difficulties with communicating
with other staff members. The debrief helps to establish whether
there are changes that can be made to improve the system in
the future.
As a medical student who is not expected to have expert
resuscitation skills, the main purpose of the debrief for Melanie
is emotional support.
5. Summary and follow-up
A debrief usually happens pretty close to the event (although the
CISD guide reference above suggests 24-72 hours post-event).
This is often for practical reasons getting together the same
staff at another time in a shift-working environment is near
impossible. It is useful to talk about the resuscitation while it is
fresh in everyone’s mind.
Follow-up is also important. After time for reflection, Melanie
may have other questions and other thoughts and its essential
to address these. The attending physician should arrange to
meet Melanie again and let her know of any follow-up case
meeting, for example if the case is being presented at an M+M
meeting.
References
1.
Salas et al, (2008) Debriefing medical teams: 12 evidence-based best practice
tips, The Joint Commission Journal on Quality and Patient Safety, 34(9):518-527.
http://www.wpahs.org/sites/default/files/file/DebriefingMedicalTeams_000.pdf
2.
Mitchell, JT. (1983) When disaster strikesThe critical incident stress debriefing,
Journal of Emergency Medical Services, 1983, 13(11):49-52.
3.
Dyregov, A. (1997) The process of psychological debriefing, Journal of
Traumatic Street, 10:589-604.
4.
Kinchin, David (2007). A Guide to Psychological Debriefing: Managing
Emotional Decompression and Post-Traumatic Stress Disorder London, UK and
Philadelphia, PA, USA: Jessica Kingsley Publishers.
5.
Ahmed, M., Arora, S., Russ, S., Darzi, A., Vincent, C., & Sevdalis, N. (2013).
Operation debrief: a SHARP improvement in performance feedback in the
operating room."Annals of surgery,"258(6), 958-963.
6.
Dyer, K. The potential impact of CODES on team members: examining medical
education training, American Academy of Experts in Traumatic Stress, accessed
online on 27th March 2014, http://www.aaets.org/article95.htm
Other Resources
7.
The London handbook for debriefing, Imperial College, London, 2010, accessed
online on 26th March 2014 at http://www1.imperial.ac.uk/resources/
EE125DD5-63D9-48AB-8A77-F2951610CD83/lw2222ic_debrief_book_a5.pdf
8.
May, N, It’s good to talk – debrief in the emergency department, St Emlyn’s Blog,
accessed online on 26th March 2014 http://stemlynsblog.org/good-to-talk-
debrief-in-the-emergency-department/
Expert Response continued
About the Expert
Tessa Davis (@TessaRDavis) is a Pediatrics Registrar at Sydney Children’s Hospital. She is the founder and
genius behind Don’t Forget the Bubbles blog and the director of iClinicalApps.
Medical Education In Cases Series | Volume 2 19
This case provoked considerable online discussion among
the contributors and learners. A number of themes emerged
from the comments. Highlighted below are some key issues
for learners and faculty members to consider when they
encounter a situation that may require a debrief.
What might you actually say?
Dr. Woods suggests that attendings can facilitate debriefing
by asking a simple question: “[T]hat was a tough shift, is
there anything you want to discuss? Letting the
conversation, thereafter, be steered by the learner (Melanie)
and her needs.
Dr. Loice Swisher outlined her actual answer to the question
of how one might approach Melanie:
If you do this long enough you will make decisions that cause a
patient pain, suffering and death - probably more than once. It
is even more problematic in emergency medicine where we
have to make rapid decisions with inadequate and incomplete
data often having no established prior rapport with the patient
or family. Yes, to err is human. Medical mistakes are now
thought to be the 3rd leading cause of death in the US.
However, Melanie, for you this is not one of them. You acted
admirably at the level of your training. The outcome is not your
fault. At this stage you need to recognize the difference of sick
and not sick and when you are in over your head needing help.
You did that.
Jeffery Hill suggested that starting with something akin to:
"No matter how long I'll work in this job, I'll never get used
to the death of a young patient." He then described how he
would reaffirm the things that Melanie did very well: First,
she recognized sick versus not sick and second, she realized