By Stacey Kusterbeck
As a physician educator, Terrell Caffery, MD, FACEP, sees many emergency medicine residents struggle with non-technical skills. “This typically manifests itself as complaints from patients,” says Caffery, section chief of Louisiana State University’s emergency medicine residency program.
Those patients say their EP was rude or did not care about them. Many times, the resident in question is completely unaware there was any problem. Although the patient’s negative feedback is given to the resident, the reality is the root cause started long before the visit. “If these issues are not addressed during their training, the physician carries these behaviors with them into their practice after residency,” Caffery explains.
The problem is the resident is communicating to some degree, but is not really connecting with the patient. “It is difficult to identify the particular area in which the individual is deficient, although we can usually tell that there is a problem,” Caffery says.
Physician educators found it frustrating because they lacked a clear way to assess these important communication skills. “Measuring, and more importantly giving actionable feedback on non-technical or interpersonal skills, is very difficult,” Caffery admits.
Caffery and colleagues were looking for a way to objectively assess patient/physician interactions in the ED. “We wanted to use those assessments to give better feedback to learners on their interpersonal interactions,” Caffery explains.
Researchers used an observational tool to assess emergency medicine residents’ non-technical skills in patient interactions. “This tool allows us to consistently measure several important interpersonal domains to pinpoint the reasons why the interaction is suboptimal,” Caffery reports.
Investigators categorized skills in four domains, using the CARE acronym: Connect with the patient, Adjust the interaction according to the patient’s needs, Resolve patient requests, and Empathize with patients. Faculty observed 34 residents during ED clinical encounters, and rated them as either acceptable or unacceptable.1 Residents were aware they were under observation, but still performed unacceptably.
Residents addressed patients appropriately only 31% of the time. An “unacceptable” rating was an indication that in the opinion of the observer, the resident did not establish rapport. “This is crucial in the ED setting, where life-or-death decisions must be made quickly in conjunction with patients and their families,” Caffery says.
With an objective tool to assess physician/patient interactions, the next step is to use the data to provide individualized, actionable feedback to residents. “We want to improve those interactions and have an interventional plan for improvement,” Caffery shares.
There are two planned interventions. One, provide residents with verbal scripts for addressing the patient (and all family members in the room) upon entering. Two, ensure residents demonstrate appropriate body language or positioning relative to patients. “Our intervention plan consists of lectures, small group sessions, and simulated patient encounters, focusing on patient-centered communication and care,” Caffery reports.
Another group of researchers is seeking to improve residency training with a focus on adaptive expertise. “It’s impossible for trainees to see all diseases, or all possible presentations of those diseases, within the construct of residency training,” explains Michael Gisondi, MD, inaugural vice chair of education in the department of emergency medicine at Stanford.
On any ED shift, providers might encounter uncommon diseases or presentations they never saw in training. “Therefore, we need to teach residents problem-solving skills for those times when they see a condition they have never encountered before but are still responsible for effectively treating,” Gisondi suggests.
Gisondi gives the example of heart arrhythmias, which are seen every day in the ED. Heart rates may be fast or slow, and blood pressure can be high or low. EPs use foundational knowledge of heart anatomy, electrophysiology, cardiac pharmacologic agents, and ECG interpretation to manage the condition.
“That is me using my routine expertise, which I need to solve routine problems. But the first time I recognize Brugada syndrome [a rare, possibly deadly, heart rhythm], I need to transfer all that knowledge to solve this never-before-seen problem. That is adaptive expertise,” Gisondi explains.
Gisondi and colleagues authored a paper on adaptive expertise in emergency medicine residency training.2 “Most learners develop routine expertise, but not all students effectively develop adaptive expertise. We want to understand how and why,” Gisondi says.
Gisondi and co-authors defined adaptive expertise, described why it is important to emergency medicine, and reviewed educational principles used to develop adaptive expertise in learners. “Adaptive expertise reduces medical error,” Gisondi asserts. “It comes down to problem-solving as a learned skill.”
One technique to teach problem-solving for the purpose of developing adaptive expertise is practice in a simulation center. This increases case variability of disease presentations. “These instructional methods are used to constantly assess one’s foundational knowledge and then fill learning gaps so that the problems to be solved have been seen before,” Gisondi says.
Without these important skills, EPs risk premature closure when making diagnoses. Misdiagnoses happen because of hindsight errors or simple confusion. “Good problem-solvers have discovery of new ways to attack a problem through intentional struggle experiences during training,” Gisondi says.
The reality is all EPs encounter something new virtually every day. “We are master problem solvers,” Gisondi adds. “Think how much better we would be if we were also adaptive experts.”
REFERENCES
1. Caffery TS, D’Antonio C, Pogue D, Musso MW. Pilot study for assessing nontechnical skills in emergency medicine residents: Why we should C.A.R.E. Ochsner J 2022;22:43-47.
2. Branzetti J, Gisondi MA, Hopson LR, Regan L. Adaptive expertise: The optimal outcome of emergency medicine training. AEM Educ Train 2022;6:e10731.
Researchers studied how to objectively assess patient/physician interactions in the ED. They used an observational tool to assess emergency medicine residents’ non-technical skills in patient interactions. This tool allows educators to consistently measure several important interpersonal domains to pinpoint the reasons why interactions are poor.
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