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Teheux L, Kuijer-Siebelink W, Bus LL, Draaisma JMT, Coolen EHAJ, van der Velden JAEM. Unravelling underlying processes in intraprofessional workplace learning in residency. MEDICAL EDUCATION 2024; 58:939-951. [PMID: 37990961 DOI: 10.1111/medu.15271] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND To deliver high-quality collaborative care, residents need to be trained across the boundaries of their medical specialty (intraprofessional learning). The current literature does not provide insights into the underlying processes that influence intraprofessional learning. The aim of this study was to gain insight into the processes that occur during intraprofessional workplace learning in residency training, by exploring everyday intraprofessional interactions experienced by residents, with the ultimate objective of improving collaborative practice. METHOD We conducted a focused ethnography using field observations and in-depth interviews with residents at an academic children's hospital in the Netherlands. In 2022, nine residents from four different medical specialties were shadowed and/or interviewed. In total, >120 hours of observation and 10 interviews were conducted. Data collection and analysis were conducted iteratively and discussed in a research team with diverse perspectives, as well as with a sounding board group of stakeholders. RESULTS Residents were involved in numerous intraprofessional interactions as part of their daily work. We identified three themes that shed light on the underlying processes that occur during intraprofessional workplace learning: (1) residents' agency, (2) ingroups and outgroups and (3) communication about intraprofessional collaboration. CONCLUSIONS Collaborative practice offers many intraprofessional learning opportunities but does not automatically result in learning from, with and about other specialties to improve intraprofessional collaborative care. Overarching the identified themes, we emphasise the pivotal role of the resident-supervisor dyad in facilitating residents' engagement in the learning opportunities of complex intraprofessional care. Furthermore, we propose that promoting deliberate practice and shared responsibility in collaborative care are crucial to better prepare residents for their roles and responsibilities in delivering high-quality collaborative patient care.
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Affiliation(s)
- Lara Teheux
- Department of Pediatrics, Radboud University Medical Center, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Wietske Kuijer-Siebelink
- Department of Research on Learning and Education, Radboud University Medical Center, Radboudumc Health Academy, Nijmegen, the Netherlands
- School of Education, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Lotte L Bus
- School of Education, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Jos M T Draaisma
- Department of Pediatrics, Radboud University Medical Center, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Ester H A J Coolen
- Department of Pediatrics, Radboud University Medical Center, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Janiëlle A E M van der Velden
- Department of Pediatrics, Radboud University Medical Center, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
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Tjan TE, Wong LY, Rixon A. Conflict in emergency medicine: A systematic review. Acad Emerg Med 2024; 31:538-546. [PMID: 38415363 DOI: 10.1111/acem.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/04/2024] [Accepted: 01/07/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The emergency department (ED) is a demanding and time-pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual-, team-, and systemic-level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research. METHODS Online databases PubMed and Web of Science were systematically searched for relevant peer-reviewed journal articles in English with keywords relating to "conflict" and "emergency department," yielding a total of 29 articles. RESULTS Narrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual-level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team-level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems-level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships. CONCLUSIONS In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.
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Affiliation(s)
- Timothy Edward Tjan
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lee Yung Wong
- Emergency Department, Austin Health, Melbourne, Victoria, Australia
- School of Business, Law and Entrepreneurship, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Andrew Rixon
- Department of Business, Strategy and Innovation, Griffith Business School, Griffith University, Brisbane, Queensland, Australia
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Amick AE, Schrepel CP. Assertiveness as a tool to prevent and mitigate inter-physician conflict. MEDICAL EDUCATION 2024; 58:366-367. [PMID: 38212133 DOI: 10.1111/medu.15305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 01/13/2024]
Abstract
Amick and Schrepel comment on the value of incorporating assertiveness into best practices for inter‐physician communication and conflict mitigation.
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Affiliation(s)
- Ashley E Amick
- Emergency Medicine, University of Washington, Seattle, Washington, USA
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Kerins J, Smith SE, Tallentire VR. "Ego massaging that helps": a framework analysis study of internal medicine trainees' interprofessional collaboration approaches. MEDICAL EDUCATION ONLINE 2023; 28:2243694. [PMID: 37535844 PMCID: PMC10402837 DOI: 10.1080/10872981.2023.2243694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Patient care depends on collaborative practice. Debate remains as to the best approach to providing education for collaboration, with educational interventions often far removed from the realities of the clinical workplace. Understanding the approaches used for collaboration in clinical practice could inform practical strategies for training. For internal medicine trainees, this involves collaboration with other professions but also with other specialties. This study aimed to explore the approaches that internal medicine trainees use for interprofessional collaboration and the ways that these approaches vary when internal medicine trainees interact with different healthcare provider groups. METHODS Following ethical approval and participant consent, interprofessional communication workshops between August 2020 and March 2021 were audio recorded and transcribed verbatim. Workshops involved groups of internal medicine trainees discussing collaboration challenges and the approaches they use in clinical practice. This framework analysis study used the interprofessional collaboration framework described by Bainbridge and Regehr (building social capital, perspective taking and negotiating priorities and resources), and cross-referenced the categorised data with the healthcare groups that trainees collaborate with, to look for patterns in the data. RESULTS Seventeen workshops, involving 100 trainees, were included. Trainees described relationship building, perspective taking and negotiating priorities and resources. Relationship building was a modification to the original framework domain of building social capital. Themes of power and civility transcended domains with evidence of using hierarchy as leverage when negotiating and employing civility as a tactical approach throughout. DISCUSSION This bi-dimensional analysis highlights patterns of perspective taking when collaborating with other specialties and professions, and the approaches to negotiation of courting favour and coercion when interacting with other specialties. This study provides evidence of the strategies currently utilised by internal medicine trainees, with different healthcare groups, and presents a modified framework which could inform the development of training for collaboration.
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Affiliation(s)
- Joanne Kerins
- Scottish Centre for Simulation and Clinical Human Factors, NHS Forth Valley, Larbert, UK
- Acute medicine, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Samantha Eve Smith
- Scottish Centre for Simulation and Clinical Human Factors, NHS Forth Valley, Larbert, UK
- Medical Education Directorate, NHS Lothian, Edinburgh, UK
| | - Victoria Ruth Tallentire
- Scottish Centre for Simulation and Clinical Human Factors, NHS Forth Valley, Larbert, UK
- Medical Education Directorate, NHS Lothian, Edinburgh, UK
- Medical Directorate, NHS Education for Scotland, Edinburgh, Scotland, UK
- College of Medicine and Vetinary Medicine, University of Edinburgh, Edinburgh, Scotland, UK
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Amick AE, Schrepel C, Bann M, Watsjold B, Jauregui J, Ilgen JS, Lu DW, Sebok-Syer SS. From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:1076-1082. [PMID: 37043749 DOI: 10.1097/acm.0000000000005226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice. METHOD The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated. RESULTS The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict. CONCLUSIONS I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.
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Affiliation(s)
- Ashley E Amick
- A.E. Amick is assistant professor, Department of Emergency Medicine and Department of Internal Medicine, University of Washington, Seattle, Washington
| | - Caitlin Schrepel
- C. Schrepel is assistant professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Maralyssa Bann
- M. Bann is assistant professor, Department of Medicine, University of Washington, Seattle, Washington
| | - Bjorn Watsjold
- B. Watsjold is assistant professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Joshua Jauregui
- J. Jauregui is associate professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Dave W Lu
- D.W. Lu is associate professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Stefanie S Sebok-Syer
- S.S. Sebok-Syer is assistant professor, Department of Emergency Medicine, Stanford University, Stanford, California
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Schrepel CP, Amick AE. Applying action-project method to untangle interphysician conflict. MEDICAL EDUCATION 2023; 57:113-115. [PMID: 36346233 DOI: 10.1111/medu.14969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Affiliation(s)
| | - Ashley E Amick
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
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Kennedy K, Cornelius T, Ansari A, Ring J, Kisuule F. Six steps to conflict resolution: Best practices for conflict management in health care. J Hosp Med 2022; 18:360-363. [PMID: 36546335 DOI: 10.1002/jhm.13031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Kierstin Kennedy
- Hospital Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Teresa Cornelius
- Hospital Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Aziz Ansari
- Division of Hospital Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois, USA
| | - Jeffrey Ring
- Independent Practice, Los Angeles, California, USA
| | - Flora Kisuule
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Zhang W, Wong LY, Liu J, Sarkar S. MONitoring Knockbacks in EmergencY (MONKEY) – An Audit of Disposition Outcomes in Emergency Patients with Rejected Admission Requests. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:481-490. [PMID: 36081749 PMCID: PMC9448349 DOI: 10.2147/oaem.s376419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Emergency Department (ED) clinicians commonly experience difficulties in referring patients to inpatient teams for hospital admission. There is limited literature reporting on patient outcomes following these complicated referrals, where ED requests for inpatient admission are rejected – which study investigators termed a “knockback”. Purpose To identify disposition outcomes and referral accuracy in ED patients whose admission referral was initially rejected. Secondary objectives were to identify additional patient, clinician and systemic factors associated with knockbacks. Selection and Methodology Emergency clinicians prospectively nominated a convenience sample of patients identified as having knockbacks over two time periods (Jan–Feb 2020 and Aug 2020 to Jan 2021) at a tertiary Australian ED. Data were analyzed with a mixed-methods approach and subsequent descriptive and thematic analyses were performed. Results A total of 109 patients were identified as knockbacks. The referrals were warranted, with 89.0% of cases (n = 97) ultimately requiring a hospital admission. In 60.6% (n = 66) of the admissions, patients were admitted under the inpatient team initially referred to by the ED, suggesting referrals were generally accurate. The number of in-hospital units involved in the admission process and ED length of stay were positively correlated (0.409, p < 0.001). Patient factors associated with knockbacks include pre-existing chronic medical conditions and presenting acutely unwell. Analysis of clinicians’ perspectives yielded recurring themes of disagreements over admission destination and diagnostic uncertainty. Conclusion In this patient sample, emergency referrals for admission were mostly warranted and accurate. Knockbacks increase ED length of stay and may adversely affect patient care. Further focused discussion and clearer referral guidelines between ED clinicians and their inpatient colleagues are required.
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Affiliation(s)
- Wendell Zhang
- University of Melbourne Clinical School, Austin Health, Heidelberg, VIC, Australia
| | - Lee Yung Wong
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
- Correspondence: Lee Yung Wong, Austin Hospital Emergency Department, 145 Studley Road, Heidelberg, 3084, VIC, Australia, Tel +613 9496 5000, Fax +613 9496 3572, Email
| | - Jasmine Liu
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
| | - Soham Sarkar
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
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Watling CJ. On identity, agency and (sub)culture. MEDICAL EDUCATION 2022; 56:592-594. [PMID: 35246876 DOI: 10.1111/medu.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Christopher J Watling
- Department of Oncology, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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