Audit and feedback for individual practitioners in the emergency department: an evidence-based and practical approach

Shifting paradigms: A collective and structural strategy for addressing healthcare inequity

Healthcare inequity is a persistent systemic problem, yet many solutions have historically focused on "debiasing" individuals. Individualistic strategies fit within a competency-based medical education and assessment paradigm, whereby professional values of social accountability, patient safety, and healthcare equity are linked to an individual clinician's competence. Unfortunately, efforts to realise the conceptual linkages between medical education curricula and goals to improve healthcare equity fail to address the institutional values, policies, and practices that enable structural racism. In this article, we explore alternative approaches that target collective and structural causes of health inequity. We first describe the structural basis of healthcare inequity by identifying the ways in which institutional culture, power and privilege erode patient-centred care and contribute to epistemic injustice. We then outline some reasons that stereotypes, which are a culturally supported foundation for discrimination, bias and racism in healthcare, cannot be modified effectively through individualistic strategies or education curricula. Finally, we propose a model that centres shared values for leadership by individuals and institutions with consistency in goal setting, knowledge translation, and talent development. Figure 1 summarises the key recommendations. We have provided cases to supplement this work and facilitate discussion about the model's application to practice.

Integrating training, practice, and reflection within a new model for Canadian medical licensure: a concept paper prepared for the Medical Council of Canada

In 2020 the Medical Council of Canada created a task force to make recommendations on the modernization of its practices for granting licensure to medical trainees. This task force solicited papers on this topic from subject matter experts. As outlined within this Concept Paper, our proposal would shift licensure away from the traditional focus on high-stakes summative exams in a way that integrates training, clinical practice, and reflection. Specifically, we propose a model of graduated licensure that would have three stages including: a trainee license for trainees that have demonstrated adequate medical knowledge to begin training as a closely supervised resident, a transition to practice license for trainees that have compiled a reflective educational portfolio demonstrating the clinical competence required to begin independent practice with limitations and support, and a fully independent license for unsupervised practice for attendings that have demonstrated competence through a reflective portfolio of clinical analytics. This proposal was reviewed by a diverse group of 30 trainees, practitioners, and administrators in medical education. Their feedback was analyzed and summarized to provide an overview of the likely reception that this proposal would receive from the medical education community.

Towards quality assurance: implementation of a POCUS image archiving system in a high-volume community emergency department

BACKGROUND

Quality assurance review is an integral part of point-of-care ultrasound (POCUS) programs but may not be routine practice in community hospitals. Lack of image acquisition and documentation can result in suboptimal patient care. In cases with an adverse outcome and no record of images, there is no mechanism for quality improvement.

OBJECTIVES

Our goal was to implement a system of POCUS image archiving in a community hospital. Our SMART (Specific, Measurable, Actionable, Realistic, Timely) aim was to have > 50% of emergency department (ED) POCUS users archiving scans, and > 80% of all billed POCUS scans archived, measuring improvements bi-weekly over a period of 9 months.

METHODS

The study was conducted at a single-community ED between August 2020 and April 2021. The POCUS archiving workflow was developed and refined through multiple plan-do-study-act (PDSA) cycles. Surveys, stakeholder meetings, audits, and feedback were used to generate and re-evaluate the interventions. These included introduction of QPathE© software, streamlining of the workflow process, strategic machine placement, POCUS rounds, use of a website for POCUS workflow instructions, and dissemination of audit results. Scans were tracked biweekly, and indexed by the number of scans billed. The primary outcome measure was the number of POCUS scans archived per 100 scans billed.

RESULTS

Over a 9-month period, spanning 72,986 ED visits, 550 scans were archived. The percentage of POCUS users who changed practice to consistently archiving scans was 51%. The rate of POCUS scans archived per 100 scans billed was > 80%, compared to no archiving at baseline.

CONCLUSION

We were able to transition from a system with entirely unarchived POCUS scanning, to one with > 80% of scans archived over a period of 9 months. This is the first published paper documenting implementation of a POCUS image archiving system in a Canadian Community ED.

"I made a mistake!": A narrative analysis of experienced physicians' stories of preventable error

RATIONALE, AIMS, AND OBJECTIVES

The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how generalist physicians make meaning of and grow from their medical errors.

METHODS

This study used a narrative inquiry approach to conduct and analyse in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analysed them for key components, and rewrote a "meta-story" in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice.

RESULTS

Through analysis we interpreted the story of a physician who is required to make numerous decisions in a short period of time in different clinical environments among the patient's family and whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the clinical supervisor can help optimize the physician's emotional growth and professional development. Similarly, through sharing and learning from stories, colleagues and trainees can also contribute to the growth of the protagonist's character and the development of clinic, hospital, and healthcare system.

CONCLUSION

We draw parallels between the clinical setting and a generalist physician's experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.