Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED ...providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.
The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit.
Patients' understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake.
The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.
Diagnostic uncertainty abounds in medicine, and communication of that uncertainty is critical to the delivery of high-quality patient care. While there has been training in communicating diagnostic ...uncertainty directed towards residents, a gap remains in preparing medical students to understand and communicate diagnostic uncertainty. We developed a session to introduce medical students to diagnostic uncertainty and to practice communicating uncertainty using a checklist during role-play patient conversations.
This virtual session was conducted for third-year medical students at the conclusion of their core clerkships. It consisted of prework, didactic lecture, peer role-play, and debriefing. The prework included reflection prompts and an interactive online module. The role-play featured a patient complaining of abdominal pain being discharged from the emergency department without a confirmed diagnosis. Students participated in the role of patient, provider, or observer.
Data from an anonymous postsession survey (76% response rate; 202 of 265 students) indicated that most students (82%; 152 of 185) felt more comfortable communicating diagnostic uncertainty after the session. A majority (83%; 166 of 201) indicated the session was useful, and most (81%; 149 of 184) indicated it should be included in the curriculum.
This virtual session requires few facilitators; has peer role-play, eliminating the need for standardized patients; and is adaptable for in-person teaching. As its goal was to introduce an approach to communicating diagnostic uncertainty, not achieve mastery, students were not individually assessed for proficiency using the Uncertainty Communication Checklist. Students felt the session intervention was valuable.
Health professions education has benefitted from standardized patient (SP) programs to develop and refine communication and interpersonal skills in trainees. Effective case design is essential to ...ensure an SP encounter successfully meets learning objectives that are focused on communication skills. Creative, well-designed case scenarios offer learners the opportunity to engage in complex patient encounters, while challenging them to address the personal and emotional contexts in which their patients are situated. Therefore, prior to considering the practical execution of the patient encounter, educators will first need a clear and structured strategy for writing, organizing, and developing cases. The authors reflect on lessons learned in developing standardized patient-based cases to train learners to communicate to patients during times of diagnostic uncertainty, and provide suggestions to develop a set of simulation cases that are both standardized and diverse. Key steps and workflow processes that can assist educators with case design are introduced. The authors review the need to increase awareness of and mitigate existing norms and implicit biases, while maximizing variation in patient diversity. Opportunities to leverage the breadth of emotional dispositions of the SP and the affective domain of a clinical encounter are also discussed as a means to guide future case development and maximize the value of a case for its respective learning outcomes.
Publishing a manuscript in an academic journal represents more than just 'promotional currency.' It provides the opportunity to provoke debate, share your experiences, and challenge the status quo on ...provider practices. Writing a manuscript relies on collaboration and shared responsibility from a research team, which can often challenge mentors as they supervise and guide its development. While there are numerous online resources and peer-reviewed journal articles on 'How to write a scientific article,' we aim to tackle an even larger and overarching theme that transcends specific journal categories, writing styles, and citation formatting. In order to guide new researchers in navigating the expansive ocean of scientific publications, we collected, reviewed, and revised 11 tips based on multiple focus-group discussions with junior and senior researchers to determine common barriers for publishing manuscript. The goal is to help mentors and mentees navigate the research and publication processes. The tips include: 1) recognizing leadership styles; 2) initiating the groundwork; 3) establishing backup plans; 4) making a deadline; 5) courting the editor; 6) determining authorship; 7) finding personal incentives; 8) writing what you know; 9) sharing with caution; 10) following directions; and 11) Consider open-access journals.
Neurosyphilis is a dangerous and increasingly more prevalent sexually transmitted infection of the central nervous system caused by the bacterium
that can present during the advanced stages of the ...disease (tertiary syphilis). Health care providers must remain vigilant in screening for syphilis in patients with high-risk behaviors as a delay in diagnosis and treatment may lead to symptom progression and debilitating sequelae years later. To date, there have been no published simulation case studies on neurosyphilis. This simulation case, based on a real patient encounter, is written for emergency medicine residents to diagnose and manage a patient presenting with the sequelae of neurosyphilis. This case was run for four separate iterations at a simulation center with two residents and an attending physician acting as confederates. Following the case, learners were provided with bedside debriefing, and a question and answer session. Based on post-simulation qualitative assessment, junior residents alone were less likely to perform a comprehensive integumentary exam without the presence of senior residents, although both groups failed to elicit pertinent sexual history until they discovered syphilitic lesions. After case completion and debriefing, all learners were able to demonstrate the understanding of the primary learning objectives.
Medical simulation competitions have become an increasingly popular method to provide a hands-on "gamified" approach to education and training in the health professions. The most well-known ...competition, SimWars, consists of well-coordinated teams that are tasked with completing a series of mind-bending clinical scenarios in front of a live audience through 'bracket-style' elimination rounds. Similarly, challenging hazards amidst observational simulation (CHAOS) in the emergency department (ED) is another novel approach to gamification in both its structure and feel. Conducted at the Council of Emergency Medicine Resident Directors (CORD) 2018 National Assembly in San Antonio, Texas, instead of assigning premeditated teams, it placed random Emergency Medicine (EM) faculty, residents, and medical students together in teams to test them on a variety of fundamental EM content areas. Additionally, the event incorporated multiple levels within each round, allowing the inclusion of additional information to be shared with participants to support "switching gears," as is typical for teams working in the ED and augmenting the perceived level of "chaos." To assess this pilot project, formal quantitative and qualitative feedback was solicited at the end of the session. Quantitative evaluation of the intervention was obtained through an eight-item questionnaire using a five-point Likert-type scale from 19 of the 20 enrolled participants (95% response rate). Responses were generally positive with an overall course rating score of 4.45 out of 5 (SD +/- 0.62). Qualitative feedback revealed that learners enjoyed performing procedures and networking with their EM colleagues. The majority of residents (95%) recommend the activity be integrated into subsequent conferences. Areas for improvement included shorter cases and minimizing technical malfunctions. CHAOS in the ED was a successful pilot study that incorporated gamification as a means to deploy simulation-based training at a national emergency medicine conference in a community of simulation educators. Future studies should focus on incorporating learners' feedback into subsequent CHAOS iterations and reducing overhead costs to increase its adoption by both regional and national audiences.
Scholarship is an essential part of academic success. Junior faculty members are often unfamiliar with the grounding literature that defines educational scholarship. In this article, the authors aim ...to summarize five key papers which outline education scholarship in the setting of academic contributions for emerging clinician educators.
The authors conducted a consensus-building process to generate a list of key papers that describe the importance and significance of academic scholarship, informed by social media sources. They then used a three-round voting methodology, akin to a Delphi study, to determine the most useful papers.
A summary of the five most important papers on the topic of academic scholarship, as determined by this mixed group of junior faculty members and faculty developers, is presented in this paper. These authors subsequently wrote a summary of these five papers and discussed their relevance to both junior faculty members and faculty developers.
Five papers on education scholarship, deemed essential by the authors' consensus process, are presented in this paper. These papers may help provide the foundational background to help junior faculty members gain a grasp of the academic scholarly environment. This list may also inform senior faculty and faculty developers on the needs of junior educators in the nascent stages of their careers.
Abstract Introduction The following simulation case is intended to prepare clinicians for a case of massive esophageal variceal bleeding in which the patient is unstable in a community hospital ...setting and a gastroenterologist/endoscopist is unavailable. The case is based on an actual case that presented through the emergency department and was admitted to a community hospital intensive care unit. The case offers a unique opportunity to practice with a gastroesophageal balloon tamponade (GEBT) device (Sengstaken-Blakemore tube or Minnesota tube)—a piece of equipment that is infrequently used and rarely trained with, but potentially lifesaving in certain clinical settings. Methods While running the simulation, a senior (third-year) emergency medicine resident manages the case while a junior resident, intern, and medical student participate in the resuscitation. An emergency medicine faculty member observes from behind a one-way glass and acts as the instructor. After the simulation case is completed, a debriefing was held followed by GEBT device instruction and practice. Results We initially tested the simulation scenario with a total of 5 participants (1 medical student, 1 intern, 1 junior resident, and 2 senior residents). An additional medical student volunteered to act as the patient. Simulation participants performed well with the initial evaluation, resuscitation, and airway management during the initial portion of the simulation session. On pre-and posttest evaluations using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) participants indicated increased comfort with making the decision to use a GEBT (pretest mean = 2.82, posttest mean = 3.8), and comfort with actually using a GEBT (pretest mean = 2.12, posttest mean = 3.8). Discussion This simulation case offers a unique opportunity to practice with a GEBT device. During the simulation session, participants accurately identified the major concerns, initiated appropriate resuscitative treatments, and discussed emergent consultations. They also considered using a balloon tamponade device but were initially unable to appropriately use the device. After training and a practice session, all participants had improved abilities and comfort levels with the GEBT device, as compared to baseline levels in untrained individuals.
Healthcare costs in the United States have skyrocketed over the past decade, contributing to an estimated $750 billion in wasteful spending annually. Despite the demand to improve residency education ...on value-based, cost-conscious healthcare, there is no consensus on how to best teach this practice. Traditional lectures have failed to demonstrate enduring change in clinical practice patterns, provider attitudes, and reductions in hospital expenditures. We sought to evaluate whether gamification is an effective pedagogical tool to teach cost-consciousness to emergency medicine (EM) residents by creating a 60-minute interactive session based on the popular gameshow, the Price is Right. Costs and associated charges for common laboratory tests, radiographic studies, medications, and common physical resources typically found in the emergency department (ED) were first obtained through direct communication with the ED clinical director and hospital leadership. The session itself consisted of three phases with several Price-is-Right-themed games, which included realistic visual stimuli reminiscent of the gameshow that were created by the authors using the PowerPoint. Formal quantitative and qualitative feedback was solicited at the end of the session. Quantitative evaluation of the educational intervention was obtained through a 22-item questionnaire using a five-point Likert-type scale from 19 of the 22 enrolled residents (86% response rate). Responses were generally very positive with an overall course rating score of 4.16 (SD +/- 0.90). Qualitative feedback identified learners' predilection for gamified delivery of nonclinical content during conference. The majority of residents (89%) recommend the activity to be used in subsequent offerings to other learners. With healthcare costs on the rise, our feasibility study demonstrated that gamification is an effective way to teach mindful, cost-conscious care to EM residents. Gamification offers a fun and engaging alternative that should be further utilized in EM educational formats. Future studies are needed to longitudinally assess the learner retention and cost-containment practices.
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