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General Medicine

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Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative
   Case Study of Physician-Faculty Perspectives
Special Article: Physician Burnout-The Experience of Three Physicians
Brief Review: Dangers of the Electronic Medical Record
Finding a Mentor: The Complete Examination of an Online Academic 
   Matchmaking Tool for Physician-Faculty
Make Your Own Mistakes
Professionalism: Capacity, Empathy, Humility and Overall Attitude
Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
   Conviction
Comparisons between Medicare Mortality, Readmission and 
   Complications
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
    Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
   the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
   Hospital Performance Measures And Outcomes 

 

Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.

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Saturday
Jun272015

Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative Case Study of Physician-Faculty Perspectives

Tara F. Carr, MD

Guadalupe F. Martinez, PhD

 

Division of Pulmonary/Critical Care, Sleep and Adult Allergy

Departments of Medicine and Otolaryngology

University of Arizona College of Medicine

Tucson, AZ

 

Abstract

Evaluation plays a central role in teaching in that physician-faculty theoretically use evaluations from clinical learners to inform their teaching. Knowledge about how physician-faculty access and internalize feedback from learners is sparse and concerning given its importance in medical training. This study aims to broaden our understanding. Using multiple data sources, this cross-sectional qualitative case study conducted in Spring of 2014 explored the internalization of learner feedback among physician-faculty teaching medical students, residents and fellows at a southwest academic medical center. Twelve one-on-one interviews were triangulated with observation notes and a national survey. Thematic and document analysis was conducted. Results revealed that the majority accessed and reviewed evaluations about their teaching. Most admitted not using learner feedback to inform teaching while a quarter did use them. Factors influencing participants use or disuse of learner feedback were the a) reporting metrics and mechanisms, and b) physician-faculty perception of learner credibility. Physician-faculty did not regard learners’ ability to assess and recognize effective teaching skills highly. To refine feedback for one-on-one teaching in the clinical setting, recommendations by study participants include: a) redesigning of evaluation reporting metrics and narrative sections, and b) feedback rubric training for learners.

Introduction

Teaching is at the heart of academic medicine. Evaluation plays a central role in teaching in that clinical teachers, theoretically use evaluations from learners to inform their teaching (1,2) Feedback has been identified as a critical component of evaluation, and by extension, medical education training (3-6). National accreditation agencies emphasize the need for the ongoing meaningful exchange of feedback between learners and physician-faculty (7,8)

The learner perspective has dominated feedback research (9-14). These studies examine how physician-faculty deliver feedback, and how learners absorb the content and delivery of feedback. Physician-faculty also assume the role of learner when medical students and trainees serve as evaluators and provide feedback about physician-faculty teaching. In response, physician-faculty develop perceptions about the quality and context of feedback from learners that shape their receptiveness of that feedback, and teacher self-efficacy (15-18). Yet, only four studies consider context and explore factors that influence feedback receptiveness of physician-faculty (15, 19-21).   Only one study examines how physician-faculty respond to learner feedback to make adjustments to their teaching (15). Previous studies have also uncovered the important idea of “source credibility." (11,14,20,22).  They find that the impetus for both effective learning and teaching adjustment comes from the feedback recipient’s trust in the evaluators’ credibility. A limitation of these studies is the lack of attention to the feedback reporting mechanisms used by their institutions, leaner-teacher contact time, the establishment of relationships, and the various factors that go into trusting or valuing learner feedback. These perceptions play an essential role in how we understand educational exchanges between teacher and learner. As such, the purpose of this study is to recognize physician-faculty perceptions about the feedback process in relationship to their teaching practice.

Knowledge about how physician-faculty access and internalize feedback from learners is sparse (22), much less faculty recommendations for improving the process. This is concerning given the important role feedback plays in clinical training. This study aims at broadening the understanding of how physician-faculty access and internalize written feedback from learners while considering contextual factors that shape the overall feedback experience for physician-faculty. We qualitatively examine if and how learner feedback influences physician-faculty receptivity and incorporation of feedback critiques into their teaching practice. In supporting inquiries, we ask: To what extent do physician-faculty access and use feedback and why (or why not)? What factors shape their decisions to incorporate (or not incorporate) learner feedback into their teaching practice?

Methods

Exempt from human research approval by the site’s Institutional Review Board, this cross-sectional case study explored feedback internalization among medicine physician-faculty at a southwest academic medical center (23). The ethical conduct to maintain anonymity and inhibit coercion was exercised and articulated to participants. Participation was voluntary and without monetary compensation.

Case study research in the social science calls for the use of multiple data sources to gain understanding of an issue using a bounded group (24,25). As such, three data sources were included in analysis and to triangulate findings. First, purposeful selection was used to identify physician-faculty whose lived experiences in the department would assist us in understand the issue (26). Physician-faculty were introduced to the study’s purpose at a routine faculty meeting where voluntary participation was elicited.

Twelve of 15 (80%) full-time medicine subspecialists participated. Sometimes mistaken as a limitation of qualitative case study design is the relative small sample size; our interview numbers not only meet the general qualitative research sample size criterion of five to 30 interviews (27-30) but focuses on obtaining information-richness in the form of quality, length and depth of interview data and supporting evidence from additional sources that answer the research question. (Table 1).

Table 1. Sample Demographics.

Original interview questions were created (Appendix A). Individual semi-structured open ended interviews were conducted during the Spring of 2014. Follow-up interviews on two participants were conducted in early February of 2015 once promoted from mid-level to full professor. The same interview protocol was used to capture changes in perspective from full professors in the effort to expand the insight pool of senior professors.

During the preceding three years, all physician-faculty in the department received e-feedback at the end of rotations from learners that includes evaluation of their individual teaching. E-feedback was designed by the college’s medical education program directors. Forms were 9-point Likert scale with an optional written comments section after each question. To gather information regarding the internalization of feedback, we asked physician-faculty to recollect past e-feedback through their tenure at the study site. Interview questions asked participants to describe their access to evaluations, and internalizations of feedback. Interviews lasted between 30-60 minutes, were audio recorded, and transcribed. Transcripts were de-identified, and demographic information reported was limited. Reporting of narratives was truncated to capture central points and stay within the word count limitation. Participants from outside institutions and departments were not included in this study as evaluation tools may include different reporting mechanisms. Additionally, we wanted to capture and understand the current subculture that exists regarding feedback and teaching that is particular to one local clinical department.

Secondary data were: observation notes, and annual ACGME trainee survey results. Observation notes were taken by the principal investigator to memorialize each interview exchange, physician-faculty education meetings (e.g. faculty meetings, clinical competency committee meetings), and clinic exchanges also during Spring of 2014 (31). Given that the principal investigator is also a physician-faculty member, an insider researcher approach (32) allows the design to include her notations as she is acutely attuned to the daily lived experiences of the participating physician-faculty. The advantage of implementing this approach is that the principal investigator understands the participants’ academic values, current work environment, insider language and cues for accurate and trustworthy behavioral notes. Observation notes were taken to document behavior at education meetings where program evaluation and physician-faculty development was discussed. Disadvantages of being an insider could lead to bias, assumptions about meanings, and overlooking of routine behaviors that could be important. A quasi-outside researcher and non-physician-faculty member in the department served as a collaborator to counter insider researcher assumptions and bias.

Physician-faculty interviewed also partook in the 2013-2014 annual ACGME anonymous online trainee survey in the Spring of 2014. Trainee ratings of physician-faculty commitment to GME programs, and perceived satisfaction the program’s perceived use of evaluations to improve rotations could further validate whether or not physician-faculty use evaluations to inform their teaching. (Appendix B).

Data were analyzed using qualitative software, QSR Nvivo10©. Using a holistic and cross-case analysis approach (25), thematic coding was used to identify patterns in access to feedback, and receptiveness on interview data and observation notes. Axial coding was then used to hone in on specific challenges/strengths in feedback from learners. Once identified, selective coding was conducted to detect themes and redundant assertions so as to ensure that no new information was emerging. Last, document analysis of the ACGME survey results was conducted. Implementing the In-between-triangulation method (33), codes from observation notes and the ACGME survey results were linked through memos to interview data. Member checking between the principal investigator and co-investigator regarding themes, terms, and categorizations occurred to ensure data trustworthiness as defined by Guba (34) (Appendix C).

Results

Access, review, and (dis)use

A significant proportion of physician-faculty accessed and reviewed feedback about them when available (10/12: 83%). The majority of physician-faculty revealed that they do not use learner feedback to make adjustments to their teaching (9/12; 75%). One physician-faculty member summarized the group’s sentiments and disclosed, 

“Not at all. The verbal feedback from my colleagues and boss makes me more cognizant of my behavior and I modify it appropriately; whether it was a success, I’ll let them judge. The written eval[uation]s from [learners] has never changed [my teaching] because they go from horrible to great and they are not useful.”-S11

Only a quarter, all of whom were junior faculty, reported utilizing learner feedback to alter teaching (3/12; 25%). Evidence that the majority of physician-faculty may not be using learner feedback to adjust teaching is broadly, but further corroborated by the ACGME survey data. Although 100% of trainees in this GME program reported having the opportunity to evaluate physician-faculty, less than 70% (which was very close to the national average) reported satisfaction with the program and physician-faculty using learner evaluations to improve. Despite this rating, these learners also reported that physician-faculty were interested in the educational program, and created an environment of inquiry at the rate of 100% (Appendix B). Furthermore, from observation notes taken during daily clinical discussions, it was noted that physician-faculty did not discuss their weaknesses with each other; especially regarding their teaching skills. Finally, when conversations regarding national conferences arose in physician-faculty education meetings or informal social settings, physician-faculty did not dialogue about attending conferences for the specific reason of improving or learning new teaching skills.

Factors influencing (dis)use

Physician-faculty identified several factors shaping their decisions to incorporate learner feedback into their teaching. To begin, just over half (7/12; 58%) reported that the metric used was problematic. When asked what they found valuable or disposable in reporting mechanisms, physician-faculty attested: 

 “A one-to-one evaluation rather than [the software we use] would be more valuable because…the numerical feedback is not very good. They need directed questions. There are non-substantive comments.” - S11

 “The numbers are worthless. I’d rather get comments that say,’ the bedside teaching was excellent, but he should work on his didactic session and change the graphics on that PowerPoint,’ but I never get that.” - S04

Second, differences in the perception of the learners emerged. Observation notes documenting contact time, relationship establishment and perspectives on fellows, specifically, revealed that physician-faculty tended to label learners in “good/bad” categories based on a combination of professional conduct, and medical knowledge base. “Good fellows” were the desired learner in the clinical setting. These learners were discussed and seen frequently in the company of physician-faculty at grand rounds, academic half days and departmental social gatherings. From observation, five physician-faculty had a following of learners who were similar to them in personality traits, interests or career aspirations. These physician-faculty and learners had a relationship, and it was evident at both social and academic gatherings as evident by the quality, duration and topic of verbal engagement, and physical proximity. Not all physician-faculty observed had this type of following and engagement.

Expanding on the observation of categorization and relationship establishment, physician-faculty reflected on their overall experience with learners and reported a general concern with the learners serving as evaluators. As a result, they cited this as a major reason for the disuse of feedback to inform their teaching (9/12; 75%). Concerns were grounded in the context of a) inadequate contact time, b) learners’ teaching fund of knowledge, and c) feedback being foregrounded in whether or not the learner takes a personal liking to the attending. When asked what their visceral reaction was to learner feedback, physician-faculty stated,

“I think you should limit it to somebody who has prolonged exposure to you. Most [learners] are only exposed to you for a few days…I think it’s more about the person doing the eval[uation] than the faculty member’s teaching ability. So I don’t hold learner feedback in high regard.” - S07

“I don’t think they know what a good teacher is….most [learners] just anchor their eval[uation] based on whether they like someone or not, so there’s not a rigorous evaluation of teaching methods.”- S04

These issues relate to physician-faculty skepticism about learners’ abilities to assess the teaching skills of their attending. There was a perception that learners were either: a) not knowledgeable about teaching methods and feedback, or b) scared to give honest feedback to physician-faculty because of the fear of retaliation. Nearly all physician-faculty reporting concerns with learner feedback knowledge recommended they receive a rubric as a tool to not only guide their feedback, but educate them about the evaluation process, and help identify “teaching moments” (7/9; 78%). Physician-faculty remarked,

“They might not know when the teaching is happening… I don’t think they know how that works and what that standard is... they don’t notice it…a lot of the teaching can be seen as unconventional. A rubric for them might be helpful…they need to be educated on evaluation.“- S10

Conversely, only two physician-faculty reported using learner feedback to adjust their teaching (2/9; 22%). They noted,

“[Learners] have been exposed to a lot of teaching and have a sense of what is effective and works for them. So part of our job is to be an effective teacher for different learners so if we’re not an effective teacher for certain learners we need to know about that…in a sense everyone is qualified… It doesn’t mean that one person who says you are not an effective educator is correct. We can’t please everyone, but we can work towards it.”- S11

 “…I try to establish relationships with the residents and fellows, and unfortunately or fortunately, it is easier for me to talk to them that way.”- S01

Learners’ experiences with numerous teachers and styles throughout their physician training were valued by the latter example. They perceived that learners had enough knowledge and experience to provide valid and competent feedback. Additionally, they saw it as their responsibility to adjust teachings and approach the teacher-learner construct as a bidirectional relationship. This is consistent with teacher-learner relationships noted in the observation settings.

Discussion

The implications surrounding learner feedback and how physician-faculty internalize and use feedback to inform their teaching practices are substantial. In sum, physician-faculty in our study did not hold learner feedback in high regard. Extending the work identifying the issue of “source credibility” in feedback (3,11,14,20,22), a key finding that adds dimension to this concept is that physician-faculty in our study use learner feedback to adjust teaching practices based on the specific value they placed on learners’ past education experiences and competency regarding teaching skills and assessment. Results suggested that source credibility is further shaped by communication and existence of a relationship between the two parties given that study participants discussed viewing the dyad as “relationship”. Supporting a recent framework, “educational alliance” introduced by Telio and colleagues (3), this idea of a relationship implies an investment, and value in each other’s roles and contributions. The quality of the relationship and communication matters as it appears to play a role in the development of physician-faculty perceptions about their learner and by extension, receptiveness to learner feedback. If such an alliance is developed, physician-faculty could then draw more informed conclusions about learner credibility that could subsequently shape their use of learner feedback. When considering the context of resident and fellow learners, this underscores the importance of national Resident-as -Teachers programs as the intent of these programs is to build a teaching fund of knowledge for trainees. Research examining their effectiveness from the perspective of seasoned physician-faculty is needed. Additionally, future studies assessing correlations between faculty who place high value on learner feedback and credibility with increased recognition as effective teachers would greatly add to our understanding of this complex issue.

Findings also highlighted the importance of appropriate feedback metrics and mechanisms. Physician-faculty reported dissatisfaction with the metrics of the institution’s online evaluation system, and their corresponding narrative sections. They recommended rubric training for the learners to refine feedback for one-on-one teaching. Looking to our results, we support and propose a feedback rubric that is deployed via a purposeful training. To set the stage for feedback to occur as a process, rubric training could require learners to undergo brief training at their respective orientations on both the use of the rubric and importance of quality narrative feedback for program improvement and physician-faculty development. Rubric for each metric that incorporates rich descriptions could scaffold and improve the critical thinking process involved in writing constructive feedback narratives for learners. Moreover, comment boxes on evaluation reporting mechanisms with either prompts or ideal substantive comment examples could help learners’ better articulate meaningful feedback for physician-faculty and make connections with rubric scoring guides. This approach forces a reconceptualization of the role of learner feedback that is different. With the training and implementation of feedback rubric for learners, this places them in the role of teacher and expert evaluator. This alters the traditional paradigm and forces physician-faculty to expect more of learners and facilitates a system to further train learners in teaching and evaluation skills.

Finally, rubrics could include moderate tailoring to address abbreviated contact time, ensure anonymity, and review institutional safeguards against physician-faculty retaliation against the learner. A limitation of current feedback frameworks (3) is the lack of attention to how limited duration of contact time, and desire for anonymity, could impact quality communication and the establishment of a relationship. Consequently, physician-faculty being evaluated should undergo parallel training to understand context in which learners have been instructed to reflect and formatively evaluate their teaching practices given a varied set of learning/teaching conditions that consider the aforementioned obstacles. We encourage the development and testing of such tools as a next step.

Limitations

A limitation of our study is the restriction to one department and over-representation of junior faculty. Physician-faculty were not asked to disaggregate feedback by the type of learner. Differences between physician-faculty perceptions of medical students versus residents versus fellows may have emerged. Despite these limitations, findings provide critical insight into what gives rise to the receptiveness of learner feedback while providing an honest report on why physician-faculty use or disuse evaluations to inform their teaching.  

Conclusion

Our study evaluates the value physician-faculty place on individual learner feedback about their teaching in the clinical setting. Despite the centrality of feedback in medical education training, physician-faculty predominantly accessed, reviewed, but disused feedback from learners to inform their teaching. This is due to the reporting mechanisms and concern over credibility of the learner; specifically, their ability to assess and recognize effective teaching skills. The introduction of feedback rubric training for learners could advance learning and contribute to sound evaluation as they are important sources of information for identifying and improving teaching and evaluation skills.35 Physician-faculty need to be able to trust and value the feedback they receive. Credible feedback shapes the decisions they make when selecting appropriate professional development opportunities, thus, shaping the quality of our medical training programs.

Acknowledgements

We would like to thank Karen Spear Ellinwood, PhD, JD and Gail T. Pritchard, PhD for the Academy of Medical Education Scholars (AMES) Teaching Scholars Program for providing a platform from which to design and conduct the study. We also wish to thank the faculty members who participated in this study, for their time and candor.

Declaration of Interest

No declarations of interest.

 

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Reference as: Carr TF, Martinez GF. Credibility and (dis)use of feedback to inform teaching : a qualitative case study of physician-faculty perspectives. Southwest J Pulm Crit Care. 2015;10(6):352-64. doi: http://dx.doi.org/10.13175/swjpcc076-15 PDF

Tuesday
Apr142015

Special Article: Physician Burnout-The Experience of Three Physicians

Robert A. Raschke, MD

University Banner Good Samaritan Medical Center

Phoenix, AZ

Our fellowship held a discussion on physician burnout which was facilitated by Kris Cooper PhD, a psychologist who has long experience working with struggling physicians. We were joined by three physicians who volunteered to share their personal experiences regarding burnout. Each of these three physicians are exceptional in their devotion to their profession, high self-expectation, and level of professional achievement. Yet the commendable personal characteristics they share may have actually set them up to ultimately suffer burnout. Each of them responded to burnout in a different way.

The first physician is an intensivist who left work suddenly 6 months ago, likely never to return. Over a long career, this physician had earned the respect of his colleagues and was beloved by the nurses for seeming to always knowing the right thing to do and dedicating himself fully to the care of the sickest patients and their families. For most of his career he rarely experienced anxiety even under the most stressful situations - “I did not even know really what it meant to be anxious”. He typically slept soundly 8 hours a night no matter what had happened at work. But nearing the end of his career he felt he had been floundering, essentially “propped-up” by the housestaff and his partners as he became progressively unable to function. At the time of his sudden departure, he was suffering unremitting insomnia, anxiety, and low self-confidence. He routinely avoided taking the sickest patients. His anxiety became so severe that he suffered anticipatory nausea even when simply accepting hand-off of the ICU service by phone.   

He relates the beginning of his professional difficulties to seven years previously when his wife of 20 years unexpectedly announced her intention to divorce him. This was emotionally highly traumatic and essentially caused a situation of unremitting stress both at work and at home. He recalled often having to deal with divorce lawyers even while at work – once having been called by a lawyer while was trying to run a code. He was not able to remediate his marriage. The process was frustrating and costly, however, he was able to seemingly recover over a prolonged course. He continued functioning at a high level at work during this process and for a number of years afterwards however he found himself socially isolated and with new financial worries.

Several years later a series of complaints were lodged against him at work. In one case, he was reprimanded for publically berating a colleague regarding an inappropriate patient transfer to the ICU. Several of his patients suffered bad outcomes and were submitted for peer review. However, the reviewers were not intensivists, and he felt were not truly “peers” in the sense that they couldn’t relate to the types of decisions required in ICU emergencies. In one case, a hematologist criticized his decision to give activated factor VII to a patient who was coding from uncontrollable obstetrical hemorrhage after the blood bank was unable to provide plasma. It was decided that his action in this case was outside the standard of care, although the reviewer did not offer any therapeutic alternative. In another incident, the physician extubated a patient who was subsequently unable to maintain independent breathing. Attempts to reintubate were unsuccessful and consequently fatal. In each case, the physician knew he had done the best he possibly could for the patient, but this chain of events cumulatively resulted in enduring workplace anxiety and a loss of self-confidence. Although he continued to provide good patient care, he felt he was “faking it”, by avoiding the sickest patients and leaning heavily on residents and fellows. He sometimes asked as many as three physicians (a critical care colleague, surgeon, and anesthesiologist) to back him up when one of his patients required endotracheal intubation, although his airway skill level demonstrated over the long course of his career was excellent.

A tremor which he had suffered with for several years worsened, making it even more difficult to perform procedures. He complained of neck pain and arm weakness but a neurological evaluation was unrevealing. He was repeatedly sick with the stomach flu and upper respiratory tract infections. He was diagnosed with depression, anxiety and post-traumatic stress disorder (PTSD), but prescription medications provided no benefit and seemed to worsen somatic complaints. Insomnia became unremitting. He would go for weeks on end, sleeping only a few hours per night, or not at all. Although he was overcome by anxiety, he became detached from more situationally-appropriate emotions – relating that he could run a code, watch the patient die, then “go right to the doctor’s lounge and eat a cheeseburger”- as though his feelings about things that were happening around him were irrelevant. The realization that he could no longer go on this way hit him suddenly and somewhat expectedly, although in retrospect it should have been obvious much sooner.

Up to 50% of physicians and nurses experience “burnout” at some point in their career – the highest incidence is in critical care (1). Burnout is characterized by the triad of emotional exhaustion, depersonalization, and a loss of any satisfaction in doing your job. It is caused by long term exposure to emotionally demanding situations in an environment of high responsibility and low control. Physicians with high empathy and high self-expectation and introspection are particularly at risk. It is associated with having made mistakes, perceptions of unreasonable work demands, feeling unsupported by the organization, and interpersonal conflicts. Symptoms include somatic complaints, frequent minor illnesses, social withdrawal, cynicism, exhaustion, and feeling underappreciated and overworked. Burnout may overlap with compassion fatigue, PTSD, depression, anxiety, alcoholism and drug abuse in some providers. The risk of suicide is increased by 600% for physicians, particularly female physicians.

The first physician said that he had a number of strikes against him, and took a number of wrong turns along the way. He recalled coming home from work exhausted many nights, and having no one to talk to, but at the same time, turning down opportunities to socialize more with friends. He felt he sometimes created more workplace stress than necessary by futilely resisting the hospital administration on a number of trivial issues. His partners were supportive, but really did not understand enough about what he was going through to effectively help him. He waited too long to get himself out of the environment.

But since removing himself from the ICU, he has been slowly improving under professional guidance. At this point, he has been away from work for about six months. [Many of the ICU staff – nurses and physicians alike – consider him the finest doctor they have ever worked with, and often ask when he can return.] But he is fairly certain that he will ever be able to return to work in the ICU.

The second physician is a highly respected intensivist who retired about a year ago, unrelated to burnout. He was described by the first physician as “the best intensivist that I ever met over the course of my career”. However, the second physician suffered significant setbacks and frustration that greatly reduced enjoyment of his career. He distinguished himself as being “fed-up” vs. being burned-out by saying that if we asked him to come into the ICU tomorrow to cover a shift, he would be eager to chip-in.

He also distinguished himself from the first physician by acknowledging that his wife of 42 years had been a huge source of support throughout the course of his many professional setbacks.

In the 1980s, in an era long before the practice of palliative care was accepted, he recalled being approached by several families of patients with end-stage COPD. At the time such patients often suffered through prolonged courses of futile ventilatory support before dying. He made a personal decision to instead offer these patients the option of morphine palliation. This was of clear benefit to his patients, but was considered well outside the standard of care at the time. He was accused of performing euthanasia, and his medical license was threatened. He was offered a deal to continue practicing medicine if he would desist and admit that what he had been doing was wrong. But his wife reassured him that he was doing the right thing and advised him not to give in. He successfully fought the complaint and continued practice. He earned a reputation for being one of the hardest-working, dedicated, and experienced physicians in the city.

In the 1990s, at the peak of his career, he diagnosed a patient with Miller Fisher variant of Guillain Barré, and placed a subclavian line to accomplish therapeutic plasmapheresis. He had previously placed perhaps thousands of subclavian lines over the course of his career. This time however, he lacerated the subclavian artery during the procedure. The patient suffered a life-threatening hemothorax requiring emergent surgical repair. The patient slowly recovered over a month-long ICU stay, during which the physician rarely left the hospital. But despite the eventual favorable outcome, he was sued, and a settlement was not reached. The case went to trial. He recalls that his wife sat in court with him every day. Ultimately he was exonerated by the jury, and he feels his wife’s constancy at his side was likely favorable in their eyes. But the cumulative stress of the traumatic and prolonged legal process changed how he felt about coming to work in the ICU. He tried to return, but his partner convinced him that he needed a break from patient care. He became a successful researcher for a few years. Then he tried his hand at general internal medicine “which was terrible – unless you enjoy writing Percocet scripts for everyone”. He even did a stint as an administrator, which he felt was a mistake in retrospect “you can't make yourself into something you are not”. Eventually, he found his way back to critical care, which he still says is “in my DNA”. Although now retired, he enthusiastically volunteers to do locums work in the ICU (but only with his wife’s approval) and remains a highly effective bedside intensivist and great favorite of the entire ICU staff.

This physician felt several things helped explain his ability to survive the difficult tribulations of his career. He credits his wife being by his side, and his work partner for actively intervening when he was floundering but did not see that he needed a break from patient care. He also thinks his personal philosophy helped him deal with setbacks. “Essentially, bad things happen in the ICU. If you gave it all that you could, you ought to be able to live with yourself, no matter how things turn out. If you cannot do that, you won’t last long in the ICU”.

The third physician pioneered his specialty in the state of Arizona. When he went into single practice in the 1980s, he estimates that he went at least three years without having a single night that wasn’t interrupted by a pages or phone calls. On top of his rapidly growing patient practice, he travelled around the state, lecturing at dozens of venues to establish his specialty in the state. As his practice grew, physicians started to refer him their most complicated patients, many of whom already had complicated medical-legal issues before he was involved. This resulted in his being included in multiple law suits. At one point he was named in over two dozen open suits. Even though he was not found guilty of malpractice in a single case, the cumulative stress of repeated medical legal conflicts took a heavy toll on him. He felt that there was absolutely no support available from the hospitals he worked at, or from professional societies of that time period. He became irritable, angry, and increasingly disengaged. “If you want to know if you’re burned-out, just ask your wife”. He began suffering a series of physical complaints including headaches, palpitations, blepharospasm, and symptoms of irritable bowel for which extensive medical workups were negative. Finally one day he snapped. His pager went off for the ten-thousandth time, and he put his fist through the wall, and told his wife “that’s it – I’m though with (expletive deleted) medicine”.

Fortunately his partners supported his decision to step back from patient care, but advised him to concentrate his considerable experience and interpersonal and organizational skills into the administrative side of their practice. He subsequently achieved a high level of accomplishment and job satisfaction, and currently runs the national professional society of his specialty.

This physician subsequently became a strong advocate for recognition of physician burnout, within his practice, and within his specialty on a national level. He offered some good advice for the audience: Learn what burnout is. If you have the symptoms, you have to stop pretending you’re not burned-out and get professional help. If you notice behaviors of burnout in a colleague, reach out and talk to them.

He pointed out a number of ways to resist the effects of burnout:

  • Maintain harmony in your life. It’s not all about work. Family, community, your personal needs, and your spirituality should all be integrated into a healthy lifestyle.
  • Do something non-medical that you love to do every day – whether that is walking your dog, playing guitar or reading a good (non-medical) book.
  • Get some control of your work schedule and how many hours you are working. Overwork will ultimately ruin both your productivity and the quality of your care. Remember why you went into medicine.
  • Don’t build a lifestyle that fosters greed. Studies have shown that once a relatively modest income is achieved, more money does not make life more satisfying or happy. Be altruistic.
  • The best way to feel good about yourself is by helping others.
  • Meditate each day about the good things that happened and people that you helped, rather than allow your mind to ruminate on negative events and worries.
  • If you have interpersonal stress, talk to the person who is the source. Except for the occasional adversary with a personality disorder, open communication usually relieves interpersonal tensions.
  • Exercise regularly - Your brain and body are connected.
  • Don’t accept a job in which you are routinely asked to sacrifice important life experiences, such as being with your children as they grow up. These experiences cannot later be replaced by or compensated for by job promotions or greater financial income.

Reference

  1. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007;13(5):482-8. [CrossRef] [PubMed]

Reference as: Special article: physician burnout-the experience of three physicians. Southwest J Pulm Crit Care. 2015;10(4):190-4. doi: http://dx.doi.org/10.13175/swjpcc056-15 PDF

Monday
Apr132015

Brief Review: Dangers of the Electronic Medical Record

Richard A. Robbins, MD

Southwest Journal of Pulmonary and Critical Care

Gilbert, AZ

In 2009 then president-elect Barack Obama said he planned to continue the Bush administration's push for the federal government to invest in electronic medical records (EMR) so all were digitized within five years. "This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests," he said, adding that the switch also would "save lives by reducing the number of errors in medicine"(1). Now over 5 years on, it might be time to examine how EMR has impacted medicine.

Historically, similar arguments were made by Dr. Ken Kizer, then Undersecretary for Veterans Healthcare Administration (VHA), 20 years ago (2). As a physician who practiced the VA at the time, my colleagues and I welcomed EMR. It had to be better than a system where neither the chart nor the x-rays were available for pulmonary clinic most of the time (Robbins RA, unpublished observations). EMR improved this. In general, x-rays and records were available and I have little doubt that this improved healthcare. However, it came at a price. It's the later that is discussed in this review.

Waste and Red Tape

Elimination of waste and red tape are good things. However, does the EMR eliminate either? Most articles have been similar to Buntin et al. (3) who point out that "92 percent of the recent articles on health information technology reached conclusions that were positive overall". However, most represent a series of opinions, usually of healthcare administrators, rather than data. Studies which have examined efficiency data have not found such an improvement (4).

My experience suggests that EMR actually creates waste of practioners' time and increases red tape. The collection of the required superfluous information detracts from patient care. Asking every patient at every visit a family history, review of systems and reentering past medical history and surgical history is very unlikely to produce any new clinically useful information and detracts from practioners focusing on the patient's problem. The recent VA scandal resulted from a performance-measurement system through the EMR that had become bloated and unfocused requiring the recording of multiple measures (often tied to administrative bonuses) of dubious or meaningless significance (5,6). These additional clerical tasks contributed to too few physicians being unable to care for too many patients. The private setting has become similarly afflicted. Performing the ever increasing meaningless measures required for reimbursement by Centers for Medicare and Medicaid Services (CMS) or other third party carries is resulting in similar detriments in care and will likely result in outcomes similar to the VA.

In addition, the data must now be recorded on a template that is easily electronically retrievable. This saves third party clerical time because the clinic notes do not have to be abstracted. However, the clerical burden now falls onto the physician or office staff. It usually means the data is entered at least twice-once on the clinic note and once on the template. Everything from smoking to electronic prescriptions must be entered on a template. Sometimes this actually saves time but at others it is horribly detrimental. For example, yesterday my practice administrator and I spent 15 minutes trying to electronically send prescriptions to a local Walgreens pharmacy mostly because we could not electronically locate the store although we had the address and phone number. With the addition of these requirements, it now takes longer, in many cases much longer, to type the note and enter the data than it does to see the patient. This is driven by a requirement for the data to be entered in an EMR in order to receive reimbursement.

There are multiple commercially available EMRs. Each system may have its some unique issues and problems. The fact that institutions may decide to change from one EMR system to another, based on a number of factors, can have significant stress on the providers and may impact overall quality of care and safety during the “learning curve” to adapt to a new EMR. Even if the system stays with one product, there are frequent “upgrades” that require learning new processes. There is a limit to how many updates and changes can be effectively learned by physicians and other providers while maintaining efficiency. These issues need to be understood by health care administrators.

Duplicate Testing

It makes some sense that if results are available electronically that duplicate testing could be reduced. Unfortunately, the reality is that although the data might be recorded electronically, it is often not available. The various computers do not necessarily "talk" to each other and even when the do, retrieving the data can be problematic because of the multiple security hoops that need to be jumped through (remember HIPPA). Furthermore, sometimes the data is substandard. Yesterday, I saw a patient with COPD from smoking, a recurrent rectal carcinoma and a CT-PET scan positive for a 1 cm enhancing mass in the right upper lobe according to the radiologist. Yet, I could see no lesion on the small image that I could view on our computer. I decided the safest course of action was to repeat the test in 3-6 months. Had I been able to review an adequate image, the need to repeat the test might have been avoided. Similarly, other x-ray, laboratory and other data is frequently inaccessible.

CMS is largely responsible for this oversight. Although the federal government has spent over 30 billion in tax dollars since 2009 implementing EMRs, they are not standardized across facilities (7). Similar problems occurred at the VA. Although it was one computer system, multiple vendors who supplied radiology, pulmonary function, and other equipment were electronically incompatible with the VA system.

Save Lives By Reducing the Number of Errors in Medicine

This may eventually prove to be true, but the available data suggest that at least initially the opposite may be true at least for computerized physician order entry (CPOE). For example, a survey of the house staff at the University of Pennsylvania found that a widely used CPOE system facilitated 22 types of medication errors (8). More disturbing is data that mortality increased from 2.8% to 6.6% after CPOE implementation in one pediatric intensive care unit (9). Other studies have failed to demonstrate such an increase in mortality (10).

Unavailability of the EMR

It seems rather obvious but EMRs have to be as dependable as other electronic records such as banks. Unfortunately, this is usually not the case. For example, the VA system would periodically crash. Trying to care for a patient when no data is available and no orders can be written is problematic. Incidentally, the problem of the periodic crashes was because local administrators refused to increase the server capacity at the Veterans Integrated Service Network level (EMRs can utilize huge amounts of memory) until the system did crash. There seemed no consequences to those responsible when the EMR was unavailable.

Unauthorized Access to Patient Information

Equally obvious is data stored in EMRs is vulnerable to unauthorized access just as computers from the Pentagon, banks, Target and even Sony pictures have all been hacked. It seems unlikely that the data in the EMR is as well protected as military or financial data especially given the large numbers with access to the data and the need to access the data sometimes quickly in emergency situations. Interestingly, large breeches in EMRs at the VA seemed to have occurred not through healthcare professionals but through information technology (IT) or administrative personnel (11).

Rarely, medical computers are hacked with the intent of extorting money. The hacker encrypts the files and then demands money to unencrypt the data (12). Some physicians' offices who have been hacked now keep two sets of data, one electronic and another paper not only cancelling most of EMR's advantages but resulting in the time and effort of keeping two record systems.

Health Care Professionals Spending Less Time with the Patient

Although physicians complain about the time required to complete various aspects of the EMR (in my view justifiably), observations in the hospital suggest nurses may be even more affected. A never ending list of documentation facilitated by the EMR have robbed many nurses of what they found most satisfying about their profession, bedside nursing (13).

Poor Understanding of the Medical Record

Poor understanding of patient data remains a significant problem for everyone from the patient who may find the record confusing and frightening to the healthcare administrator who is not trained or skilled in the practice of medicine. A number of medical practices are utilizing “patient portals” in their EMRs that allow patients to review their records online. The knowledge that a patient will be able to review all information entered in their record seems likely to have an effect on physician documentation, particularly in certain areas such as potential substance abuse, mental health issues, or malingering. Review of the record by the patient may also create challenges in patient care. For example, a patient who has read a radiology report that states “malignancy cannot be excluded” may question a decision by the clinician not to do a biopsy because the risks of further testing or biopsy are not justified by what may be a very low likelihood of malignance. Confusion can result in numerous bad outcomes, but usually for the patient and/or the practioner. These are all new issues and the impact overall on patient care and the doctor-patient relationship are not clear.

Control

This might be the largest potential danger and most contentious aspect of the EMR. It revolves around who owns the medical record. Some believe patients should own their record, and similarly, administrators, CMS, insurance companies and practioners all believe that the EMR should be theirs, at least in part (14). Consequently, there are conflicts regarding what should and should not be recorded. Although this argument is far beyond this brief review, the implications are far-reaching and important.

Regardless of who is the ultimate owner of the medical record, it is quite clear that administrators in the hospital and large clinics and CMS and insurance companies can dictate both the content and form. Furthermore, it is quite easy to place requirements to complete the records or receive reimbursement. For example, completion of CMS' most recent "meaningful use" measures can be required for reimbursement, and similarly, information might be required before a document can be signed. This might be reasonable unless the requests are busywork or for predominately useless information. This can detract from the usefulness of the medical record. For example, at one hospital where I practiced there was an excellent gastroenterology department. They used a computer generated report for their procedures that usually resulted in about 5 typed pages. It satisfied all CMS, insurance company, JCAHO, and professional standards. However, it was difficult (some of my colleagues said impossible) to read and interpret timely and efficiently. Increasingly, we see office reports, consults, history and physicals, radiology reports, laboratory reports, and discharge summaries which approach the length of a Dostoyevsky novel and have little utility in conveying information useful in patient care. Furthermore, should any part of the medical tome be missing (remember bundles), CMS and insurance companies will gleefully deny payment while healthcare administrators will harass both nurses and physicians to complete the medical record according to CMS and the insurance company mandates. This results in practioner inefficiency. However, the solution is usually to hire more administrative personnel to make sure that the practioners work even harder and longer further decreasing efficiency both medical and administrative inefficiency.

Not usually mentioned as a danger, although it should be, is that the EMR can be alerted by the unscrupulous who may control the EMR. For example, Sam Foote told me a story that while at the Phoenix VA, he could place a request for back magnetic resonance imaging (MRI) but would later find that the order removed. At the time the hospital had overspent its fee basis budget and was actively discouraging the ordering of MRIs. Furthermore, we have seen radiology reports altered when a misreading was discovered without evidence of the original misreading present (Robbins RA, unpublished observations).

Conclusions

EMRs represent a potential boon to patient care and providers, but to date that potential has been unfulfilled. Data suggest that in some instances EMRs may even produce adverse outcomes. This result probably has occurred because lack of provider input and familiarity with EMRs resulting in the medical records becoming less a tool for patient care and more of a tool for documentation and reimbursement.

References

  1. Jones KC. Obama wants e-health records in five years. InformationWeek Healthcare 2009. Available at: http://www.informationweek.com/healthcare/obama-wants-e-health-records-in-five-years/d/d-id/1075517? (accessed 2/27/2015).
  2. Kizer KW. Prescription for change. 1996. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 2/272015).
  3. Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). 2011;30(3):464-71. [CrossRef] [PubMed]
  4. Kazley AS, Ozcan YA. Electronic medical record use and efficiency: a dea and windows analysis of hospitals. Socio-Economic Planning Sciences. 2009;43(3):209-16. [CrossRef]
  5. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-7.
  6. [CrossRef] [PubMed]
  7. Kizer KW, Kirsh SR. The double edged sword of performance measurement. J Gen Intern Med. 2012;27:395-7. [CrossRef] [PubMed]
  8. Whitney E. Sharing patient records is still a digital dilemma for doctors. NPR. March 6, 2015. Available at: http://www.npr.org/blogs/health/2015/03/06/388999602/sharing-patient-records-is-still-a-digital-dilemma-for-doctors?utm_medium=RSS&utm_campaign=news (accessed 3/6/15).
  9. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-203. [CrossRef] [PubMed]
  10. Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-12. [CrossRef] [PubMed]
  11. van Rosse F, Maat B, Rademaker CM, van Vught AJ, Egberts AC, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics. 2009;123(4):1184-90. [CrossRef] [PubMed]
  12. Office of Inspector General. Report No. 06-02238-163. Review of issues related to the loss of VA information involving the identity of millions of veterans. Available at: http://www.va.gov/oig/pubs/VAOIG-06-02238-163.pdf (accessed 3/5/15).
  13. Murphy T, Bailey B. Is your doctor's office the most dangerous place for data? Associated Press. February 9, 2015. Available at: https://www.yahoo.com/tech/s/health-care-records-fertile-field-cyber-crime-135744306--finance.html (accessed 3/6/15). Thompson D, Johnston P, Spurr C. The impact of electronic medical records on nursing efficiency. J Nurs Adm. 2009;39(10):444-51. [CrossRef] [PubMed]
  14. N Chesanow. Who should own a medical record -- the doctor or the patient? Medscape. January 13, 2015. Available at: http://www.medscape.com/viewarticle/837393 (requires subscription, accessed 3/6/15).

Reference as: Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. doi: http://dx.doi.org/10.13175/swjpcc035-15 PDF

Monday
Dec082014

Finding a Mentor: The Complete Examination of an Online Academic Matchmaking Tool for Physician-Faculty

Guadalupe F. Martinez, PhD1

Jeffery Lisse, MD1

Karen Spear-Ellinwood, PhD, JD2

Mindy Fain, MD1

Tejo Vemulapalli, MD1

Harold Szerlip, MD3

Kenneth S. Knox, MD1

 

1Departments of Medicine and 2Obstetrics and Gynecology, University of Arizona, Tucson, AZ

3Department of Medicine, University of North Texas Health Science Center Department of Medicine, Fort Worth, TX

 

Abstract

Background: To have a successful career in academic medicine, finding a mentor is critical for physician-faculty. However, finding the most appropriate mentor can be challenging for junior faculty. As identifying a mentor pool and improving the search process are paramount to both a mentoring program’s success, and the academic medical community, innovative methods that optimize mentees’ searches are needed. This cross-sectional study examines the search and match process for just over 60 junior physician-faculty mentees participating in a department-based junior faculty mentoring program. To extend beyond traditional approaches to connect new faculty with mentors, we implement and examine an online matchmaking technology that aids their search and match process.

Methods: We describe the software used and events leading to implementation. A concurrent mixed method design was applied wherein quantitative and qualitative data, collected via e-surveys, provide a comprehensive analysis of primary usage patterns, decision making, and participants’ satisfaction with the approach.

Results: Mentees reported using the software to primarily search for potential mentors in and out of their department, followed by negotiating their primary mentor selection with their division chief’s recommendations with those of the software, and finally, using online recommendations for self-matching as appropriate. Mentees found the online service to be user-friendly while allowing for a non-threatening introduction to busy senior mentors.

Conclusions: Our approach is a step toward examining the use of technology in the search and match process for junior physician-faculty. Findings underscore the complexity of the search and match process.

Introduction

Across the spectrum of disciplines within the academy, it is well documented that mentorship is key to career advancement and satisfaction among faculty (1). For physician-faculty, mentoring is “considered to be a core component of the faculty duties…to fulfill…th(e) academic medicine mission” (2). Although important, structural barriers to mentorship still exist (2,3). Finding an appropriate mentor is critical not only in establishing a productive and engaging mentorship, but in having a successful career in academic medicine (4). However, scholars note that finding the most appropriate person is not without its challenges: especially for junior faculty (3-7,9). Some studies find that junior faculty (and faculty new to institutions) depict the search process as the most difficult step in establishing a mentorship (3,7,9,10). In these studies, mentees recommend a match process that begins with a comprehensive list of potential mentors that includes contact information (3,7). Although noteworthy, this recommendation fails to elaborate on the extent to which a mere list could improve the search and match process. How such lists are implemented or if supplemental mechanisms were used to connect unfamiliar faculty is unclear.

Prior literature stresses the importance of “effort and persistence” when embarking on a search (3,4,9). Through this seemingly daunting process, scholars specifically advise mentees to ask colleagues to connect them to others with similar interests, and invest time into researching the backgrounds of potential mentors to determine their suitability. However, there are inherent challenges to this approach. First, the time spent investigating mentor backgrounds may vary greatly depending on the number and quality of resources available to conduct such an investigation. Second, mentees new to an institution could find it difficult and/or unproductive to ask new colleagues to connect them to potential mentors as colleagues may not be able to make an appropriate connection if they are unfamiliar with the mentor pool. Although this could point mentees in the right direction, they could spend an inordinate amount of time meeting with numerous contacts only to find academic and clinical interests to be unrelated or tangentially related to theirs. Previous studies found that mentees who self-match with a mentor, are more likely to be satisfied with their mentorship experience (3,4,7,8). Yet, if the institutional mentoring culture functions as described above, mentees would have to rely solely on their division chief or department chair for an assigned mentor. This could be problematic if the chief or chair is unfamiliar with the strengths of the mentor pool.

In hallmark studies by Williams et al. (7), and Straus et al. (3), they highlight perceived barriers to mentorship from the mentee perspective, and find those to be: a) a lack of local and adequate mentor selection, b) time constraints for the mentors, c) inadequate access, and d) a lack of formal programs and mechanisms to connect faculty. Straus et al.’s (3) study also sheds light on mentees desire to choose a mentor instead of being assigned. They find that mentees perceive assigned partnerships as superficial, but that assigned matches are sometimes useful because the search process is challenging for those new to an institution. Given the conflicting perceptions, these authors call for additional strategies to improve the search and match process as well as an examination of those strategies. Methods to optimize mentees’ time and diversify searches have yet to be delineated. More importantly, the role technology could play in mentoring remains understudied. As identifying the mentor pool and improving the search process are paramount to both, a mentoring program’s success, and the academic medical community, innovative approaches are needed.

We build on the work of Straus et al. (3), and Sambunjak et al. (10) by examining the search and match process for physician-faculty mentees participating in our department-based mentoring program. In our cross-sectional study we seek to better understand internal matching behaviors and the role technology could play. We detail and explore technology aimed at improving the search and match process for our mentees. This “matching” tool further advances our knowledge about the role technology could (or could not) play in addressing the challenges associated with the search and match process. Our research questions ask: If a “matching” tool is implemented, what would the matching behavior be within the department? What are the primary usage patterns among mentees? How receptive have mentees been in adopting this mechanism to aid their search and matching efforts?

Methods

The University of Arizona’s Department of Medicine developed a department-based faculty mentoring program in March 2011 during which a needs assessment was conducted on junior physician-faculty. First, like Straus et al.’s (3) findings, mentees partaking in our needs assessment desired assistance with the search and match process. Mentees reported a lack of knowledge about available mentors, their areas of expertise, and difficulty establishing contact with senior faculty.  The committee concluded experimenting with a computer program that functioned much like an online matchmaking service would improve the process; extending matching beyond the common strategies of contact list distribution, top down assignments, and informal social forums. The committee then customized an online matchmaking program, Mentor Match© (Intrafinity Inc., Ontario), to create a “virtual space” for mentor and mentee use. The committee crafted a “one-stop shop” where faculty accessed mentor/ mentee profiles containing academic interests, department mentoring events, and mentorship contract templates (Figure 1).

Figure 1. University of Arizona department of medicine opening user console view.

It was suspected that our faculty demographics included an overrepresentation of junior faculty (assistant professor rank) as compared with the number of senior faculty (associate and full professor rank) (11,12).  Also evident was that commitments to medical students and trainees prevented senior faculty from being able to devote sufficient time to mentor junior faculty. As such, the committee piloted an interdisciplinary approach and included mentors outside the department and College of Medicine to compensate for the low number of available mentors in Medicine (e.g. Public Health).

Methodology

A concurrent mixed method design was applied. We triangulated quantitative (numerical) and qualitative (descriptive) data to provide a comprehensive analysis of the primary usage patterns related to search and match behavior, and understand satisfaction with the online tool (13). We generalized results to our sample and then explored nuances based on narrative feedback.

Implementation

With the official launch of the mentoring program in January 2012, Mentor Match© went live to connect over 100 physician-faculty and faculty-researchers. At this time, the Department of Medicine had 65 junior faculty in search of mentors. A combined total of 54 mentors (N=32 full professors; N=22 associate professors) from the Department of Medicine, Department of Emergency Medicine, and College of Public Health served as mentors for this group.

Faculty profiles include email addresses and detailed background information about each faculty member (e.g. academic track, age range, overall years teaching) (Figures 2 and 3).

Figure 2. University of Arizona department of medicine mentor/mentee profile and skills inventory.

Figure 3. University of Arizona department of medicine mentor/mentee profile and skills inventory.

Once faculty data is entered, Mentor Match© produces a complete listing of top recommended mentors based on similarities between mentees and mentors. One-on-one demonstration of how Mentor Match© works occurs during new faculty orientation. Current CVs are uploaded and available for in depth review of publication record, training history and current funding. Junior faculty can also access other junior faculty profiles in the department to form peer mentoring groups.

Participants, data, and analysis

Voluntary mid-year and annual assessments are components of the mentoring program. IRB approved questionnaires developed by the committee were disseminated to program participants as part of a broader study and program quality control. For ongoing program evaluation and to inform the committee, we collected data from five sources: a) committee meeting minutes, b) observation notes, c) human resources faculty rosters from 2011-2012; 2012-2013, d) 2011 junior faculty needs assessment report, and e) voluntary end-of-the-year questionnaires.

Study participants included only mentee MD’s, DO’s, PhD’s, MD/PhD’s, and MD/MPH’s with the rank of Assistant Professor, Lecturer or Research Scholar in the Department of Medicine on one of three faculty tracks: clinical-educator, clinical, and research.  

Cross tabulations formulated in SPSSv21 were used as part of survey analysis to compare categorical data from faculty rosters and questionnaires relevant to matching behavior and usage patterns. Qualitatively, document analysis using thematic coding for trend identification was conducted using Nvivo 10 to analyze narrative comments. Similarly, document analysis and thematic coding was implemented on committee meeting minutes, observation notes, and faculty roster to report the events and decision making process involved in the implementation of the program and matching tool (Figures 4 and 5).

Figure 4. Mentor match questionnaire (end-of-year).

 

Figure 5. Analysis coding scheme for setting description in methods and results.

 

Results

The program began with 65 mentees in January 2012. After annual faculty attrition, 72% of mentees (44/61) reported using the software and completed the voluntary end-of-year questionnaire in January 2013.

Selection patterns

Mentees were asked to report their primary use of Mentor Match©. Three usage patterns were apparent (Appendix D, Table 1.0a). Over half of mentees reported primarily using the software to search for potential mentors both in and out of the department. Almost a third of mentees reported mainly using the software to search for potential mentors within the department only. Just under 10% (4/44) of mentees reported primary usage of the software to expand their professional peer network. Slightly over half of males utilized the software to search for potential mentors both in and out of the department. However, among females, this latter usage pattern was even more prevalent (17/25; 68%). Among those reporting primary usage to search for professional network expansion, males reported this practice at a disproportionately higher rate (3/19; 15%) than that of their female counterparts (1/25; 4%).

While mentees considered the recommended list of potential mentors from Mentor Match© in their match decision, just over half reported negotiating their primary mentor selection with their division chief’s recommendations (25/44; 57%). This means that mentees discussed their search results and interests with their chief to come to an agreement about who would serve as their mentor (Tables 1-3).

Table 1. Questionnaire results: gender.

 

Table 2. Questionnaire results: Search and matching behavior after Mentor Match© implementation in the department primary use and gender cross tabulation.

 

Table 3. Match results and gender cross tabulation.

 

In this “negotiation” the mentee and chief come to a consensus instead of the chief assigning a partnership with no input from the mentee, a relatively common practice prior to this mentoring initiative. For the mentee, there is a sense of self-matching with guidance from the chief. This match pattern occurred proportionate to the respective totals of male and female mentees. An extremely small minority of junior faculty, all males, did not have mentors at the time of data collection (2/19; 10.5%). Finally, the next most common match patterns were the forced assignment (9/44; 20%) followed by the self-matched (8/44; 18%). At almost an even rate, female (5/25; 20%) and male (4/19; 21%) mentees reported considering the software’s top recommended mentors, but were ultimately assigned a mentor by their division chief. Remaining mentees (4/25; 16% females and 4/19; 21% males) reported considering the software’s recommendations, but eventually self-matched to a mentor of their choice.

Mentee feedback

The vast majority of mentees (40/44; 91%) found the software user-friendly, reporting that they would use the software for ongoing searches (Table 4). Questionnaire comments included positive feedback. Mentees’ appreciated the: a) non-threatening forum enabling access to detailed information about potential mentors, b) forum’s convenience, and c) functionality allowing access to research scholars outside the department. Finally, recommended improvements called for introductory training on website navigation, and viewing access to junior peer profiles.

Table 4. Mentee feedback.

 

Discussion

Building on Zerzan et al.’s (9) guide, we provide a robust description of implementing a software-based mentoring program. This software serves as a faculty directory and matching tool to facilitate mentors-mentee relationships in a large clinical department. Our systematic approach toward matching is a first step toward examining the use of technology to ease the search and match process for junior physician-faculty. We discovered that a “negotiated approach”, where junior faculty Mentor Match© selections were then explicitly discussed with division chiefs and department heads, was highly used and valued. Our data suggest that knowledge of local organizational culture or other information that can only be imparted through discussions with their chiefs and colleagues, are also highly valued.

Sambunjak et al.’s (10) qualitative study highlights the complexity of navigating partnerships. Our findings extend these observations to the search and match process, which is just as complex. More in-depth examination of the decision making process for those using software based matching or self-matching is needed to better understand what leads to junior faculty securing successful mentoring relationships. The shortage of mentors found in our needs assessment mirrored findings from national studies,11,12 implying that mentoring junior faculty is a challenge or not a priority compared to students, residents, and fellows. Given today’s heavy emphasis on clinical productivity and formal responsibilities teaching \ trainees at all levels, inspiring senior faculty to mentor junior faculty could be particularly difficult (5,15).  Departmental leaders and program administrators must realize mentor shortages will impact the search experience regardless of methodology employed. The consequences of not addressing barriers in mentorship may include frustration with the search process, junior faculty turnover, and erosion of an important part of the academic culture. In addition to heeding recommendations by Straus et al. (3) of providing protected time and formal recognition for mentoring, departments should foster interdisciplinary networks inside and outside of the medical discipline, leverage the emeritus professor workforce, and embrace mentor panels. Technology based mentor searches could facilitate implementation of such initiatives with the goal of improving professional satisfaction among mentees.

Limitations

Our study examines the usage patterns of and feedback on Mentor Match© from the junior faculty mentee perspective, but there are limitations. First, we have not assessed whether and how mentors use Mentor Match© to research mentees who have reached out to them. Knowing if immediate access to mentees’ backgrounds and skills assists mentors in deciding whether to accept a mentorship or refer them to a colleague could inform us about the potential benefits of this software tool for mentors. This study also draws on a small mentee self-reporting sample in one department with just over half of all junior faculty participating. Although the sample is small, particularly regarding software feedback, findings provide a starting point to learn the technological needs of faculty related to the search and match challenge. Such data helps us tailor online profiles and site navigation. Finally, we also do not know whether there is a significant advantage to “negotiated” mentorships as compared with those established solely by using Mentor Match©.

Despite these limitations our study is the first to assess the role technology could play in the search and match process for physician-faculty. Casting the online matchmaking net more broadly to include other colleges and including trainees could add another dimension toward understanding how to improve the search and matching process in academic medicine.  

Conclusion

Our study details Mentor Match© implementation and illustrates that software driven approaches can assist physician-faculty in establishing mentoring relationships. This approach may complement other search and matching efforts ongoing in departments and may be used to connect faculty across disciplines. In general, this tool continues to have a positive impact in our department, helping to achieve our goal of facilitating and expanding the mentee’s professional networks.

Acknowledgments

Role of each author in manuscript preparation:

  • Dr. Martinez is the lead author of this paper. Participation included mentoring program committee membership, IRB documentation, data collection, study design, analysis, initial manuscript draft, revision implementation, approve final version.
  • Dr. Lisse’s participation included mentoring program committee membership, questionnaire design, manuscript review/editing, approve final version.
  • Dr. Spear-Ellinwood’s participation included data member checking, manuscript review/editing, approve final version.
  • Dr. Fain’s participation included mentoring program committee membership, questionnaire design, study design, manuscript review, approve final version.
  • Dr. Vemulapalli’s participation included mentoring program committee membership, questionnaire design, study design, approve final version.
  • Dr. Szerlip’s participation included chairing the mentoring program committee, manuscript review/editing, approve final version.
  • Dr. Knox is the senior mentor on this paper. Participation included mentoring program committee membership, IRB documentation review, study design, questionnaire design, manuscript review/editing, approve final version.

Funding:

This study was partially funded by an internal educational research award by the University of Arizona College of Medicine Academy of Medical Education Scholars in November 2012 and the Department of Medicine Administration.

Secondary Publication Notice:

This descriptive article is an unabridged report. A 500 word version of the full length manuscript is under review for primary publication in Medical Education’s Really Good Stuff section. This section presents short reports that illustrate general lessons learned from innovation in medical education, and include very little data and description.

References

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Reference as: Martinez GF, Lisse J, Spear-Ellinwood K, Fain M, Vemulapalli T, Szerlip H, Knox KS. Finding a mentor: the complete examination of an online academic matchmaking tool for physician-faculty. Southwest J Pulm Crit Care. 2014;9(6):320-32. doi: http://dx.doi.org/10.13175/swjpcc138-14 PDF

Friday
Aug292014

Make Your Own Mistakes

Michael S. Chesser,  MD

 

Department of Medicine

Phoenix VA Medical Center

650 E. Indian School Road

Phoenix, AZ 85012-1892

 

One of the many adages that we collectively pass on to our medical students and residents is the concept of “making your own mistakes.” In other words, one should not compound the mistakes of others by failing to make one’s own assessments and treatment decisions. I frequently recount certain stories to my house-staff in order to illustrate how easily even conscientious doctors can violate this rule! Here is one such story.

Between the autumn of 2008 through the spring of 2009 I was assigned to Joint Base Balad in Iraq, flying Critical Care Air Transport (CCATT) with the U.S. Air Force. I was the physician on a 3 person team with the task of providing en route critical care for ICU/Trauma patients during our standard air evacuation flights on cargo aircraft. Our transcontinental flights were on the C-17, an enormous aircraft designed to transport large cargo like main battle tanks--not the critically wounded! Our patients were often on ventilators with every imaginable tube emanating from them. The typical patient was intubated and possessed many of the following: chest tubes, a suction tube coming from their still-open and packed abdomen, a ventriculostomy, external fixators on shattered limbs, or outright missing limbs. As we were often charged with flying more than one of these complex patients we had to rapidly assess them and ensure they were adequately stabilized and try to predict any of the things that could go wrong with them in flight. Once we were airborne and on our way to Germany, we were essentially on our own! Anything we failed to anticipate and have a response for could prove catastrophic as we only had the ability to run a few basic labs on a portable i-STAT device. With the noise of the aircraft I could not even use my stethoscope to any effect. We were always pressed for time as the air crew was always determined to takeoff well before the sun came up. The reason for this being that large cargo planes parked on airfields in locations where insurgents are looking to shoot anything they can at you are ripe for disaster. We typically flew these missions at night to improve our odds of reaching a safe altitude before anyone could try something nefarious. Our equipment allowance and procedures allowed for us to care for up to 6 patients at a time with up to three on ventilators.  It was quite common to have last minute patient's added on—“as we were going anyway” and “had space.” These continual changes added to the chaos, but I had at least learned to always expect my eventual patient mix to look nothing like the initial briefing that we would receive after first being alerted. 

It was in this milieu where my nurse, who I might add is a veritable icon of clinical virtue, prevented me from egregiously violating the aforementioned rule. It was shortly before midnight local time when we entered our ICU in order to get our allotment of patients ready for transport to the flight line and situated on the aircraft. This particular mission was atypical as we only had two patients assigned and neither was on a ventilator. While I was still reviewing the first patient’s chart, one of the ICU nurses made a point to approach me and tell me that our other patient was being “nasty” and “drug seeking.” I made a mental note of this and took a quick glance at him across the small ICU bay. I could tell he at least looked stable and apparently had a broken leg. My nurse was at his bedside talking to him. At this point, I diverted my attention back to what I was initially doing. It was mere moments after this that one of the ICU doctors came over to complain to me about what a “jerk” (he used much stronger language) this patient was being! The doctor was describing the patient as disoriented and abusive. Of course, the first thoughts that came into my mind were along the lines of “I so don’t have time for any nonsense from this guy…” and “just my luck to have to deal with a disruptive and difficult patient.”   

Now that the figurative poison was starting to diffuse in my mind, I felt myself start to get indignant. I was telling myself that I was in no hurry to go over and assess the second patient. Fortunately, a few moments later my nurse was next to me wearing one of her expressions I knew so well. I was immediately relieved to realize I was not the object of her frustration (this time.) I had flown with her long enough to have a few of her annoyed looks cataloged.  It was apparent that our colleagues were greatly failing to meet her expectations! In no uncertain terms, she informs me that this unfortunate soldier had a substantial hip fracture and was in immense pain. Furthermore, he was sorely under medicated. Of course, he was agitated and not on his best behavior! My sense of indignation rapidly gave way to pangs of guilt as I realized I was on the crux of perpetuating this mistake! My pen flew from my flight suit pocket to the order sheet she held to correct this omission. This “difficult” patient’s demeanor and mental status improved dramatically once we started to get better control of his pain. During the bumpy ambulance bus ride to the flight line my team and I wedged our thighs underneath his stretcher to try to lessen the bouncing and improve his comfort. He was remarkably patient with us considering how much the extra bouncing hurt him.

Over the next several hours, on the flight from Iraq to Germany, I learned more of his story. He was a middle-aged soldier who had fallen approximately 30 feet from a Blackhawk helicopter landing on unforgiving concrete below. In addition to the physical trauma, he had been subjected to the added mental torment of not being able to get into this helicopter as it was taking off. He found himself clinging frantically to the wheel, reportedly unseen by the pilot, until he could maintain his grip no longer and fell. With that mechanism of injury it was amazing that the only thing broken was his hip and a few ribs and that he was still alive! In addition, the CT scans revealed he had a relatively small amount of intracranial bleeding and some parenchymal contusion of his lung. Despite significant continued pain--especially associated with all the bumps involved in transferring someone from one continent to another using an array of stretchers, ambulance busses and military cargo planes--the patient was in pretty good spirits by the time we arrived at the ICU in Germany the following morning. He was now a huge fan of my nurse and rightfully so! A couple of days later, when we were back in Iraq my nurse presented me with a challenge coin, a small coin bearing his unit's insignia, from his assault helicopter battalion. He had called a friend in his unit expressing immense gratitude for my team and asked his friend to convey these coins to us. Anyone who has served in the military will tell you that these seemingly small trinkets are often used to mark highly meaningful events. It was at this point that I finally reflected on my own thought processes that cold desert night and heard the voice of one of my attendings from twenty-plus years ago –“Chesser, make your own mistakes.”

Reference as: Chesser MS. Make your own mistakes. Southwest J Pulm Crit Care. 2014;9(2):142-4. doi: http://dx.doi.org/10.13175/swjpcc113-14 PDF