MEdIC Series: The Case of the Justified Junior – Expert & Community Commentary

The Case of the Justified Junior presented a case of a learner that disagrees with his senior resident,  a senior resident that may be biased in her decision making, and an attending faced with the opportunity to teach around this whole situation. And at the center of it all, we have a patient that may be at risk if the wrong decision is made.

In keeping with our mandate with the MEdIC series, we launched this case last week and waited for the crowd to speak up and help us solve the case. We also asked two esteemed colleagues to prepare some expert consultations on the case.  Continue reading to see what they thought.

This month Eve Purdy (@purdy_eve) and I (@TChanMD) lead a discussion that explored a very complex scenario, and solicited with insights from the ALiEM community and 2 experts. This follow-up post includes:

• The responses of our medical education experts, Drs. Heather Murray (@HeatherM211) and Megan Ranney (@MeganRanney)
• A summary of insights from the ALiEM community derived from the Twitter  and blog discussions
• Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities

[su_spoiler title=”Expert response 1: Making Better Decisions” style=”fancy” icon=”chevron-circle”]

Heather Murray, MD MSc FRCPC
Associate Professor, Queen’s University, Department of Emergency Medicine

This case raises a number of different issues.  These issues are around:

1. Team Leadership
2. Cognitive Bias
3. Authority

1.  What is the role of the team leader?

Sam’s personal agenda of looking good for her attending and the day shift team by having a “clean board” is interfering with her role as an effective team leader. As team leader, Sam needs to consider the opinions of the other members of her team. Managing disagreement is an important leadership skill, and the first step is listening to alternate opinions in a courteous, respectful manner. Junior team members often have extensive information about patients, as they spend far more time interacting with them. The advantage of health care teams is the ability to collect and pool a diverse collection of information and knowledge to improve diagnostic accuracy. Sam should be encouraged to view Mike as an asset with information that can help her and make her job easier, rather than as a nuisance. She doesn’t have to agree with Mike’s concerns, but since she has trusted him with Mrs. Kim’s assessment she needs to give him the opportunity to express his thoughts.

2.  Is cognitive bias causing a diagnostic error?

From a risk management perspective, this case has some red flags. Sam’s decision-making at the end of a night shift amidst a competing agenda of “clearing the board” should be viewed as potentially flawed. Pat Croskerry has identified a number of cognitive biases that interfere with diagnostic accuracy. He suggests that awareness of times and patterns of risk prone decision-making (metacognition) may help alleviate diagnostic error. In front line specialities such as Emergency Medicine, the diagnostic error rates have been estimated between 10 and 15% [1].

Sam has ‘anchored’ on the idea that Mrs. Kim’s visit is for a trivial reason, and may be ignoring evidence to the contrary. As she becomes an attending physician, Sam needs to be aware of times when she has potentially flawed or biased thinking, and develop strategies to pause and check her thinking during those times. These could include shift changes, dislike of patients or team members (or other strong personal emotions), and situations when external priorities compete with patient care, like the “clean board.”

3. How do authority gradients affect medical error?

Clinical medicine has a hierarchical structure, which can make medical students reluctant to challenge more senior physicians. Mike shows this reluctance because he is both insecure about his lack of experience, and concerned about negative personal and career repercussions.

There are lessons to be learned from the military and the aviation industries about preventing error in the setting of “authority gradients.” One strategy for resolving conflict is to enlist an impartial 3rd party whenever there is disagreement between team members. Another is to coach team members in effectively communicating their level of concern. These expressions of concern should escalate from expressing impartial curiosity (“Could these symptoms be due to depression?”), to communicating a specific issue (“I’m worried that she could have an undiagnosed medical problem with all these ED visits”), and finally to expressing an immediate threat with a request for support (“She looks really sick and you need to come and see her right now.”)[2]. Mike needs to know that expressing concern about patients to clinical supervisors is always appropriate, and that structured language for communicating urgency may help him to do so more effectively.  Similarly, this may be a situation where collecting collateral information from other experienced team members (e.g. the veteran nurse who is also taking care of Mrs. Kim) is invaluable.

So… how might Mike have handled the situation better?

Mike’s empathy for Mrs. Kim is important and shouldn’t be discouraged. However, he needs to translate his intuitive worries into a more structured clinical query. A differential diagnosis for an elderly patient with frequent visits for vague, minor complaints could include elder abuse, depression, suicidality, substance abuse, cognitive impairment, delirium, and a host of other problems.  The next step in Mike’s development as a clinician is to think in terms of what might be wrong with Mrs. Kim, and how to initiate an appropriate assessment of those concerns.

Can we move away from being “wrong” towards making better decisions?
Physicians are educated with an expectation of individual perfection. This is inculcated in systems with a culture of shame and blame around medical errors. Brian Goldman has given a powerful TED talk entitled “Doctors Make Mistakes. Can We Talk About That?” which should be required viewing for physicians.  Open acknowledgement of errors is a key first step in improving patient safety. Modelling this attitude and approach for trainees is essential.

This case boils down into a dichotomous outcome where someone will be “wrong” and someone will be “right” – an attitude that necessarily pits one team member against another. Moving away from this approach towards honest, open reflection on where we can be led astray and how the team can help prevent these errors can improve patient care.

Conclusion: What would I do?

I would have a group discussion with both Sam and Mike about the potential for medical error in this case. It could include a personal anecdote of a similar case with an unfortunate outcome. It is an excellent case to raise awareness of the cognitive biases that interfere with effective decisions, the role of teams and effective team communication in preventing error, and the importance of all team members sharing responsibility for patient safety. The issue here is not who is “wrong,” but how an effective medical team can work together to guard against diagnostic errors.

References & Resources

1. Croskerry P. From mindless to mindful practice–cognitive bias and clinical decision making. N Engl J Med. 2013 Jun 27;368(26):2445-8. PMID: 23802513
2. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med. 2004; 11(12), 1341–1345. PMID 15576526
3. Croskerry P, Cosby KS, Schenkel SM, Wears RL (Eds). Patient Safety in Emergency Medicine. Philadelphia. PA. Lippincott, Williams and Wilkins, 2009.
4. Goldman, Brian. (Jan 25, 2012). Doctors Make Mistakes. Can We Talk About That? YouTube Link

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[su_spoiler title=”Expert response 2: Power Dynamics, Communication, and Trust” style=”fancy” icon=”chevron-circle”]

Megan Ranney,  MD MPH
Associate Professor, Department of Emergency Medicine, Brown University

This case raises some interesting questions about power.  We must recognize that there is a hierarchy in medicine, whether or not we want to acknowledge it.  We also must recognize that there are conflicting priorities for trainees and their supervisors.

Trainees come to our hospitals to learn, and supervisors are present to ensure maximum benefit for each patient.  Supervisors, especially in the emergency department setting, are also responsible for a variety of non-care-centered factors, including “flow,” compliance with government regulations, consultant relationships, and patient satisfaction.  The struggle of competing objectives for patient care and for trainee learning is highlighted in this case.   The two trainees have a power differential (medical student vs. supervising senior resident), but there is also a power differential with the attending physician.  Indeed, research shows that issues of power are highlighted in the training hospital (versus in community practice) [1].

Power Plays and Other Issues

Interestingly, power – the authority to make decisions, and to define the terms of an interaction – is intricately involved with issues of trust [2].  The issue of trust is particularly salient for the trainee/supervisor relationship, as illustrated in this case.  Sam didn’t trust Mike’s assessments, and Mike didn’t trust Sam’s assessments; neither trusted themselves to talk to Dr. Wittenberg about the case. Indeed, in my opinion, labeling this case as illustrating a problem of “power differentials” overlooks the true underlying issue: trust.

Many of the conflicts in this case – between Sam and Mike, but also between both of them and Dr. Wittenberg – could have been avoided had the two trainees and the attending developed trust beginning.  Studies in other healthcare settings suggest that trust is based on (a) role perceptions; (b) demonstrated competence; and (c) good communication over time [3,4].  The situation in this case occurred because of lack of clarity about Role perceptions (what was the role of the senior resident? Did the medical student still have a right to approach the attending?); Competence (on all fronts); and Communication (how to best interact in cases of conflict).

Communication issues

In this case, I’ll focus on the last issue, of communication, ignoring the role perceptions and competing priorities of all three healthcare providers.  There were a number of critical communication breakdowns throughout the night, which could have been avoided:

• Sam’s desire to “set things straight” about Mrs. Kim: this destroyed Mike’s trust in her, but also her trust in Mike;
• Mike’s lack of effectiveness in communicating his concerns; and
• Dr. Wittenberg’s lack of communication with both trainees about this case over the course of the night.

If this were me…

If I were debriefing the trainees in this situation, I would suggest the following

1. Sam needs to balance her pressures to “fly through the department”, and her innate biases about Mrs. Kim, with her in-the-moment obligation to both the patient and the trainee

One potential solution would be for Sam to elicit from Mike his reasoning for what might be wrong.  Was he concerned that she was a victim of elder abuse?  If so, Sam could counsel about proper screening techniques.  Alternatively, was he concerned that she had dementia or an undiagnosed metabolic, toxicologic, or metastatic process?  If so, Sam could counsel about next steps in a workup.  So doing may allay Mike’s concerns; would offer a terrific teaching opportunity regarding the difficult patient; and would allow Mike to develop trust in Sam’s decision making.

Additionally, I would counsel Sam on the importance of team relationships [5]. At my hospital and residency program, all members of the ED team have to complete a full-day training on team dynamics.  This program, titled Project CLEAR, teaches team members about the importance of “check backs” during critical moments, and about the importance of having all team members (some of whom may be lower on the medical hierarchy ) being comfortable with questioning the plan at all points during patient care.  This program has resulted in improved patient safety and satisfaction [6]. A similar approach may be useful for trainees like Sam [7,8].

2. Mike needs to balance his desire to “do right” by the patient and his inability to articulate his concerns

One potential solution would be to encourage him to spend a few minutes thinking about how to better phrase his concern, in a way that increases Sam’s trust.  For instance, he could say: “Sam, I need your help.  I know that this patient is a frequent flyer, but I’m concerned that today’s visit represents something bigger.  Do you have a couple of minutes to talk through the differential with me?”

3. Dr. Wittenberg needs to be available throughout the night to all of her team members

She is correctly delegating responsibility, and allowing her trainees – both of whom are on the cusp of transitioning to their next role – to explore the limits of their knowledge.

But a strong supervisor will still keep tabs on how such transitions are going.  One possibility could be that she allows Sam to run the department, but checks in regularly with both Sam and Mike to build trust and increase learning.

Conclusion

This case highlights multiple issues related to training dynamics. Some take-home points:

1. Establish good communication patterns early, especially with trainees
2. Perceived power dynamics can make even the most friendly of attendings seem aloof or distant.  If you’re an attending, make sure to check in with your housestaff.  If you’re a learner, don’t be afraid to ask and speak up!
3. There is no substitution for direct observation.

References

1. Nusu P, Greenfield P, et al. How and where clinicians exercise power: Interprofessional relations in health care. Soc Sci Med 2010. 71:898-909.
2. Gibson L. Trust in health care: theoretical perspectives and research needs. J Health Organization and Manage, 2006. 20(5):359-375.
3. McDonald J, Jayasuriya R, Harris MF. The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus. BMC Health Services Research. 2012. 12:63.
4. Chan T, Sabir K, Sanhan S, Sherbino J. Understanding the Impact of Residents’ Interpersonal Relationships During Emergency Department Referrals and Consultations. J Grad Med Educ. 2013;5(4), 576-581.  PMID: 24455004
5. Proence EJ. Team dynamics and team empowerment in health care organizations. Health Care Manage Rev 2007 32(4): 370-8.
6. Sweeney LA, Warren O, Gardner L, Rojek A, indquist DG. A Simulation-Based Training Program Improves Emergency Department Staff Communication. Am J Med Qual, 2014;29(2), 115-123.
7. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The potential for improved teamwork to  reduce medical errors in the emergency department.  The MedTeams Research Consortium. Ann Emerg Med. 1999;34:373-383.
8. Salt E, Rowles GD, Reed DB. Patient’s perception of quality patient–provider communication. Orthop Nurs. 2012;31: 169-176.

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[su_spoiler title=”The Case of the Justified Junior: Curated from the Community” style=”fancy” icon=”chevron-circle”]

The comments on the case this week fell into two major themes:

1. You’re Never Too Junior to Speak Up For Patient Safety

All of the participants fully noted that, regardless of their role or ‘rank’, all team members (including the patient and/or family members) have a role to play in being able to voice concerns. Some suggestions that the ‘crowd’ came up with for improving the process, however are:

1. Be respectful, but speak up: Respect seniority, but be willing to be curious, you never know when you might be taught or simply improve patient care;
2. Use curiosity to your advantage: As a student, ask the question if you feel you don’t understand – framing your concerns as questions signifies to the senior party that you’re willing to learn from them.  And if you’re wrong, well, then maybe you’ll learn why!
3. Admitting you are wrong (or that you have limits) is cool. Looking it up is even better (for the patient, for the learner etc..). As @TChanMD says:  “Don’t sweat it – check it!”
4. Debriefing errors in judgement can be critical. Whether you are the most senior member of the team or the most junior, misses or near-misses can be important learning experiences.  Doing so that explains the metacognitive processes and dissects the cognitive biases may be of use.

2. Role-Modelling a Team Approach to Patient Care

Whether junior or senior, doctor or patient, speaking up was something that was highly valued by all participants. Several participants (@M_Lin, @TChanMD) suggested involving all parties of a care team to formulate a plan.  Remember, each provider may have a slightly different snap shot of the patient situation, and they may provide new information.  Gathering and formalizing a process to integrate this information is key.

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Thank-you to all the participants

All of the community participants (in alphabetical order) that participated in our discussions this week were:
Dave Beam (@ER_Beamer),
Teresa Chan (@TChanMD),
Fran Crawford (@FranCrawford1)
Nadim Lalani (@ERmentor),
Gracie Leo (@Gracie_Leo)
Michelle Lin (@M_Lin)
Eve Purdy (@Purdy_Eve)
Madhusree Singh (@Thinkalot)

Case and Responses Available for Download

Click Here (or on the picture below) to download the case and responses as a PDF.

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