Teaching and evaluating multitasking ability in emergency medicine residents - what is the best practice?

Impact of process interference on memory encoding and retrieval processes in dual-task situations

Dual-tasks at the memory encoding stage have been shown to decrease recall performance and impair concurrent task performance. In contrast, studies on the effect of dual-tasks at the memory retrieval stage observed mixed results. Which cognitive mechanisms are underlying this dual-task interference is still an unresolved question. In the present study, we investigated the influence of a concurrent reaction-time task on the performance in a long-term memory task in two experiments. In Experiment 1, participants performed an auditory-verbal free recall memory task and a visual-manual spatial Stroop task in a single or dual-task condition, either at the encoding or retrieval stage of the memory task. In Experiment 2, we examined the influence of processing conflicts in a concurrent RT task on memory encoding. Both experiments showed detrimental effects on recall accuracy and concurrent RT task performance in dual-task conditions at the encoding stage. Dual-task conditions at the retrieval stage led to a slowdown in recall latency and impaired concurrent RT task performance, but recall accuracy was maintained. In addition, we observed larger Stroop congruency effects in the dual-task conditions, indicating an increased processing conflict. However, in Experiment 2, we analyzed the effect of the processing conflict in a time-locked manner and could not find a significant influence on success of memory encoding. These findings suggest that processes in both tasks share the same limited capacity and are slowed down due to parallel processing, but we could not find evidence that this is further influenced by task-specific processing conflicts.

The Effects of Displaying the Time Targets of the Manchester Triage System to Emergency Department Personnel: Prospective Crossover Study

BACKGROUND

The use of triage systems such as the Manchester Triage System (MTS) is a standard procedure to determine the sequence of treatment in emergency departments (EDs). When using the MTS, time targets for treatment are determined. These are commonly displayed in the ED information system (EDIS) to ED staff. Using measurements as targets has been associated with a decline in meeting those targets.

OBJECTIVE

This study investigated the impact of displaying time targets for treatment to physicians on processing times in the ED.

METHODS

We analyzed the effects of displaying time targets to ED staff on waiting times in a prospective crossover study, during the introduction of a new EDIS in a large regional hospital in Germany. The old information system version used a module that showed the time target determined by the MTS, while the new system version used a priority list instead. Evaluation was based on 35,167 routinely collected electronic health records from the preintervention period and 10,655 records from the postintervention period. Electronic health records were extracted from the EDIS, and data were analyzed using descriptive statistics and generalized additive models. We evaluated the effects of the intervention on waiting times and the odds of achieving timely treatment according to the time targets set by the MTS.

RESULTS

The average ED length of stay and waiting times increased when the EDIS that did not display time targets was used (average time from admission to treatment: preintervention phase=median 15, IQR 6-39 min; postintervention phase=median 11, IQR 5-23 min). However, severe cases with high acuity (as indicated by the triage score) benefited from lower waiting times (0.15 times as high as in the preintervention period for MTS1, only 0.49 as high for MTS2). Furthermore, these patients were less likely to receive delayed treatment, and we observed reduced odds of late treatment when crowding occurred.

CONCLUSIONS

Our results suggest that it is beneficial to use a priority list instead of displaying time targets to ED personnel. These time targets may lead to false incentives. Our work highlights that working better is not the same as working faster.

Capstone Simulation: A Multipatient Simulation for Senior Emergency Medicine Residents

Introduction

Emergency medicine (EM) trainees must learn to manage multiple patients simultaneously using task-switching. While prior work has demonstrated that multipatient scenarios can be an effective teaching tool for task-switching, few studies have shown how simulation can be used to assess residents' ability to manage multiple patients effectively. The goal of this curriculum was to provide a formative assessment of core EM skills by employing a series of simulations designed to require frequent task-switching.

Methods

This exercise consisted of three simulation scenarios running in sequence. The first scenario involved medical resuscitation and advanced cardiac life support, the second required learners to manage two patients involved in a trauma using advanced trauma life support, and the final scenario tested learners' ability to communicate bad news. Faculty observers used scenario-specific checklists to identify gaps in content knowledge, communication skills, and task-switching abilities during reflective debriefs. These checklists were analyzed to identify trends. All participants were sent a postsession evaluation. Items omitted by >50% of participants were flagged for review.

Results

Flagged items included asking for finger-stick glucose, verbalizing a backup intubation plan, specifying type of blood products, and asking for team input. Nine of 12 participants completed the postsession evaluation, noting that they agreed or strongly agreed the simulation was relevant and promoted reflection on task-switching skills.

Discussion

This simulation provides educators with a tool to facilitate reflective feedback with senior EM learners regarding their core resuscitation, leadership, and task-switching skills and could be further adapted to promote deliberate practice.

Novice Doctors in the Emergency Department: A Scoping Review

In many emergency departments (EDs), young, inexperienced doctors treat patients who are critically ill. At the start of their career, these novice doctors are not sufficiently qualified to take care of these potentially critically ill patients in the highly demanding environment of an ED. This not only poses a threat to the well-being of the doctor, who feels inadequately prepared and experiences a lot of stress, but also to that of the patients, who may not receive optimal care. Lastly, young doctors may influence the efficiency of the organization, with longer throughput times, more orders of ancillary investigations, and more admissions.

Training novice doctors with regard to simple or complex skills using simulation techniques is part of the solution. However, the transfer of newly learned skills to clinical practice remains unexplored, and not everything can be trained before the actual skill is required. Therefore, it is important to train young doctors in their learning abilities, for instance, teach them how to be adaptive and how to use their skills in new situations. Lastly, the way care is organized is essential. Good supervision, leaving room for the learning processes of young doctors, developing a team with more experienced professionals (paramedics, nurses, and doctors), and well-organized processes, aiming to reduce the complexity of the work, are ways to improve the quality of care, independent of the experience level of the novice doctor.

Media Multitasking in Medical Students: A Theory-Based Approach to Understanding this Behavior

PHENOMENON

While technology is useful and encouraged in medical school, the effect of media multitasking on academic performance remains concerning. Past research has investigated performance and cognitions associated with college students' in-class media multitasking behavior, but the extent and correlates among medical students is relatively unknown.

APPROACH

We surveyed medical students at our institution to quantify media multitasking behaviors and related beliefs, and we collected corresponding course grades. Our research applies the Integrative Model of Behavioral Prediction theory to analyze course and cognitive factors influencing media multitasking behavior in medical students. Correlation of media multitasking behavior with average and block grades assessed potential academic impact of the behavior.

FINDINGS

Media multitasking was common among medical students. Reported extent of media multitasking among medical students (N = 119) was not related to course grades but was driven by an interplay of beliefs about the behavior and specific course factors. Based on our hierarchical regression model, concerns about boredom appear to be the major cognitive belief underlying behavior.

INSIGHTS

Our findings, in the context of the Integrative Model of Behavioral Prediction theory, show influential factors that impact medical students' behavior regarding media multitasking. A campaign targeting these factors influencing behavior may be the most effective approach to limit students' media multitasking and its potential impact on performance. Though our research did not find an association between the extent of media multitasking and course grades, our study was limited by self-report of media multitasking and relatively crude measures of academic performance. Further research is required to measure these behaviors and potential outcomes.

Supplemental data for this article is available online at.

Paediatric resident workflow observations in a community-based hospital

Objective

Residency graduates need to demonstrate competence in prioritising safe patient care through appropriate management of multiple competing tasks and workflow interruptions. This pilot study aimed to characterise and correlate interruptions in paediatric resident workflow at an academically affiliated, community-based hospital.

Methods

One of three trained observers followed a resident physician during a convenience sample of 1–2 hour increments, either in the emergency department or on the wards, and recorded all observed activities and interruptions using an established time-motion tool. All participants completed a baseline Multi-Tasking Ability Test (MTAT) and pre-observation and post-observation surveys. Statistical approach included descriptive statistics, logistic regression, mixed model and ORs.

Results

18 paediatric residents were observed for 57.5 total hours (an average of 3.2 hours/resident) which included 329 interruptions, defined as any external event drawing the resident’s attention away from a primary task. Interruptions occurred an average of 5.9 times per resident per hour. Interrupted primary tasks were not resumed during the observation period 11% of the time. A personal/social-related interruption yielded an OR of 0.29 that the resident will return to a primary task within 5 min (p=0.007) when compared with patient-related verbal interruptions by the medical team. The MTAT Score indicated decreased efficiency for interns versus postgraduate year 2 residents (p=0.029). Residents’ MTAT Scores did not correlate with their time to return to a primary task following an interruption (p=0.11).

Conclusions

Paediatric resident workflow interruptions in the hospital were observed to occur frequently and should be expected. Personal/social interruptions were most likely to delay prompt return to a primary task. The MTAT Score, although improved between the first 2 years of residency training, did not correlate with efficient return to a primary task. Interruption management and mitigation strategies should be developed as part of a standardised residency task management curriculum.

A Simulated Scenario to Improve Resident Efficiency in an Emergency Department

Introduction

Multitasking is a core competency in emergency medicine. Simulation has been shown to be an effective method of education, which allows learners to prepare for real-world challenges in a controlled environment.

Methods

In this study, trainees were given a scenario that simulated the experience of managing two patient encounters within a time metric while addressing interruptions that take place in a typical ED. Residents were evaluated using an internally developed scoresheet, which assessed task-switching abilities, documentation skills, and adherence to door to disposition time metric. Residents were asked to evaluate their experience with a survey.

Results

All the participants reported that they would translate some of the skills learned to their daily clinical practice. Five out of six residents reported improvements in their skills as a result of the task-switching training. The following three common themes were pervasive in the debrief discussion: (1) the residents felt the added pressure of the door-to-disposition metric, (2) the objectives of the simulation did not fit within their pre-constructed concept of a successful simulation equating to establishing the correct diagnosis, and (3) the interruptions were very realistic.

Discussion

Emergency physicians are interrupted approximately every 9-14 minutes, and this number increases with the number of patients being managed simultaneously. By developing a safe, simulated training environment, we sought to transfer key strategies for improving focus and learning to prioritize while also helping them to identify how certain pressures and interruptions affected their stress levels and concentration.

The Myth of Multitasking and What It Means for Future Pharmacists

Objective The primary purposes of this study were to determine the extent to which multitasking affects the speed and accuracy with which Doctor of Pharmacy students identify prescription errors and whether there is a relationship between students' self-perception of their multitasking ability and their actual ability.Methods One hundred twenty-one second-year pharmacy students enrolled in the required course Introduction to Dosage Forms spent one week in an experimental (multitasking) condition and one week in a control (undistracted) condition. Subjects were given 10 minutes to check 10 prescriptions and record any identified filling errors. A cellular phone was placed in each room. Subjects in the experimental (multitasking) condition answered a call from a researcher posing as a talkative customer during the prescription-checking task while subjects in the control condition were not interrupted by a cell phone call during the task. Subjects' completion times and accuracy were recorded.Results When subjects were multitasking, they took significantly longer to complete the prescription-checking task than when they were not multitasking. Furthermore, when subjects were multitasking, they scored significantly lower on the prescription-checking task than when they were not multitasking. Finally, students' self-perceptions of their multitasking abilities were not related to the speed with which they completed the prescription-checking task nor to their accuracy.Conclusion Multitasking negatively affects speed and accuracy of prescription verification in student pharmacists. Our procedure can be used as an in-class activity to demonstrate the limits of attention and to shape how future pharmacists practice.

A novel approach: Simulating multiple simultaneous encounters to assess multitasking ability in emergency medicine

Study objective

The purpose of this feasibility study is to develop and validate a new assessment tool and scoring system for multitasking competency for physicians in-training in a timed simulated setting. The multitasking competency includes ability to appropriately prioritize and implement tasks for different patients who present simultaneously.

Methods

We designed three single task stations with different levels of difficulty and priority. These skill stations were then combined to create a multitasking simulation scenario. Skill checklists and the global rating scale were utilized to assess the participants’ performance. A multitasking score, multitasking index, and priority score were developed to measure the multitasking ability of participants.

Results

Thirty-three first-year postgraduate physicians were recruited for this prospective study. The total performance scores were significantly higher for the single-tasking stations than for the multitasking scenario. In terms of the time needed to complete the tasks, the participants spent more time on the multitasking scenario than on the single-tasking scenario. There were significant correlations between the global rating scale and the multitasking score (rho = 0.693, p < 0.001) and between the global rating scale and the multitasking index (rho = 0.515, p < 0.001). The multitasking score, multitasking index, and priority score did not have any significant correlations with the total single-tasking score.

Conclusion

We demonstrated that the use of a simulated multitasking scenario could be an effective method of assessing multitasking ability and allow assessors to offer better quality feedback.

Feeling the flow with a serious game workshop: GridlockED as Medical Education 2 study (GAME2 study)

OBJECTIVE

GridlockED gameplay workshops were delivered in Canada. This project investigated workshop attendees' experiences, seeking to identify learning points to inform improvement of the workshop.

METHODS

GridlockED sessions were held through 2018 and 2019. Workshops targeted medical trainees. After a standardized video, learners played for approximately 90 minutes. Learners completed a postgameplay survey with 7-point Likert scale questions about their experience.

RESULTS

Seventy-two participants responded to our survey (41 medical students, 13 physician assistant students, 12 emergency medicine residents, and six faculty members). Trainees rated GridlockED as both enjoyable and a meaningful educational experience, with a mean (±SD) rating of 6.53 (±0.96) of 7 for enjoyment and 6.17 (±1.13) for education. Attendees identified teamwork and communication (49%) as the most helpful learning domain, with patient flow (43%) being second and basics of how the ED worked (31%) being third. The respondents self-identified top areas of learning as resource management (38.9%), improved understanding of various provider roles in the ED (33%), and improved communication skills (33%).

CONCLUSION

Medical learners identified GridlockED to be an educational and enjoyable learning experience. Attendees reported that playing this serious game assisted with learning about health systems and communication.

Do Automated Reminders for Emergency Department Resident Physicians to Review Their Patient List Improve Efficiency?

OBJECTIVES

Navigating the emergency department (ED) workflow in an efficient manner is an important skill every emergency physician or advanced provider must master. There is a paucity of research into ways to improve how efficiently an ED provider works amid these distractions. This study seeks to determine whether the addition of an hourly automated reminder for resident physicians to review their patient list improves throughput metrics.

METHODS

This a double-blinded randomized controlled trial in which resident physicians at a single community ED were randomly assigned to two groups: the intervention group, which received automated hourly notifications within the electronic medical record (EMR) to review their patient list for those whose workup is completed, and the control group, which received no notifications. We prospectively analyzed records for 25,255 encounters with 19,264 individual patients seen by 64 residents over the study period. Three-level mixed-effects regression models were used to examine whether notifications improved ED length of stay (ED-LOS), turnaround time to discharge (TAT-D), or turnaround time to admission (TAT-A).

RESULTS

There was no statistically significant difference in ED-LOS or TAT-D between groups, but the average TAT-A was 20.00 minutes longer in the intervention group compared to the control group (p < 0.001), after accounting for patient- and resident-specific effects. Secondary analysis demonstrated no statistically significant effect of residency specialty on the effect of notifications on ED-LOS, TAT-D, or TAT-A.

CONCLUSIONS

Automated hourly notifications within the EMR reminding residents in the ED to review their patient list did not reduce the ED-LOS, TAT-D, or TAT-A. However, the TAT-A was 20.00 minutes longer in the intervention group compared to the control group. It is unclear whether this represents an unintended effect of the automated reminders or is simply a spurious correlation.

Exploring emergency physicians' professional identities: a Q-method study

Professional identities research in medical education has made significant contributions to the field. However, what comprises professional identities is rarely interrogated. This research tackles this relatively understudied component of professional identities research by understanding emergency medicine physicians' perspectives on the important elements that comprise their professional identities. Q-methodology was used to identify different clusters of viewpoints on professional identities; by extension, the core components that comprise emergency medicine physicians' professional identities are disclosed. Thirty-three emergency medicine physicians were recruited, through purposive sampling, from five hospitals across Taiwan. R software was used to analyse the Q-sorts, determine loadings on each viewpoint and formulate the viewpoint array. Analysis of interview data enhanced our understanding of these viewpoints. In total, twenty-five emergency medicine physicians loaded onto four distinct viewpoints, reflecting dominant perspectives of emergency medicine physicians' understanding of their professional identities. These distinct viewpoints demonstrated what emergency medicine physicians deemed significant in how they understood themselves. The viewpoints comprised: skills acquisition, capabilities and practical wisdom; coping ability and resilience; professional recognition and self-esteem; and wellbeing and quality of life. All viewpoints stressed the importance of trust between colleagues. These findings demonstrate the multitude of ways in which seemingly unified professional identities diverge across groups of individuals. An enhanced understanding of speciality work culture is gained. By understanding facets of professional identities, the development of future educational interventions and departmental initiatives, which might support key components of professional identities, can be explored.

Multitasking behaviors and provider outcomes in emergency department physicians: two consecutive, observational and multi-source studies

Background

Multitasking is a key skill for emergency department (ED) providers. Yet, potentially beneficial or debilitating effects for provider functioning and cognition are underexplored. We therefore aimed to investigate the role of multitasking for ED physicians’ work stress and situation awareness (SA).

Methods

Two consecutive, multi-source studies utilizing standardized expert observations in combination with physicians’ self-reports on stress and SA were set out in an academic ED. To control for ED workload, measures of patient acuity, patient counts, and ED staff on duty were included. Regression analyses estimated associations between observed proportion of time spent in multitasking with matched ED physicians’ reports on stress (study 1) and SA (study 2).

Results

ED physicians engaged between 18.7% (study 1) and 13.0% (study 2) of their worktime in multitasking. Self-reported as well as expert-observed multitasking were significantly associated. This confirms the internal validity of our observational approach. After controlling for ED workload, we found that physicians who engaged more frequently in multitasking perceived higher work stress (Beta = .02, 95%CI .001–.03; p = .01). In study 2, ED physicians with more frequent multitasking behaviors reported higher SA (B = .08, 95%CI .02–.14; p = .009).

Conclusions

Multitasking is often unavoidable in ED care. Our findings suggest that ED physicians’ multitasking increases stress experiences, yet, may facilitate professional’s experiences of situation awareness. Our results warrant further investigation into potentially ambivalent effects of ED providers’ multitasking in effectively sharing time between competing demands while maintaining performance and safety.

Impact of Electronic Medical Record Alerts on Emergency Physician Workflow and Medical Management

BACKGROUND

Electronic medical record (EMR) alerts are automated messages that notify the physician of important information. However, little is known about how EMR alerts affect the workflow and decision-making of emergency physicians (EPs).

STUDY OBJECTIVES

This study aimed to quantify the number of EMR alerts EPs receive, the time required to resolve alerts, the types of alerts EPs receive, and the impact of alerts on patient management.

METHODS

We performed a prospective observational study at a tertiary care ED with 130,000 visits annually. Research assistants observed EPs on shift from May to December 2018. They recorded the number of EMR alerts received, time spent addressing the alerts, the types of alerts received, and queried the EP to determine if the alert impacted patient management.

RESULTS

Seven residents and six attending physicians were observed on a total of 17 shifts and 153 patient encounters; 78% (119) of patient encounters involved alerts. These 119 patients triggered 530 EMR alerts. EPs spent a mean of 7.06 s addressing each alert and addressed 3.46 alerts per total patient seen. In total, EPs spent approximately 24 s per patient resolving alerts. Only 12 alerts (2.26%) changed clinical management.

CONCLUSION

EPs frequently receive EMR alerts, however, most alerts were not perceived to impact patient care. These alerts contribute to the high volume of interruptions EPs must contend with in the clinical environment of the ED.

SPRINT Through Tasks: A Novel Curriculum for Improving Resident Task Management in the Emergency Department

INTRODUCTION

The emergency department (ED) presents a challenging task-management environment to emergency medicine (EM) trainees. However, equipping residents with a tool to improve task switching (generically known as multitasking) could have positive impacts on patient care and physician emotional state. We designed a task-management tool and educational curriculum with the goal of improving emergency medicine resident task-switching ability.

METHODS

The task-management tool uses the acronym SPRINT: (1) stabilize critical patients, (2) perform procedures, (3) rack (see new patients in the chart rack), (4) in or out (reassess and disposition), (5) type it up (chart completion). These tasks and their order were decided on by two seasoned clinicians based on their years of experience in the ED. The SPRINT tool was taught to EM residents through a 1-hour curriculum consisting of an introductory video, a classroom-based workshop with multimedia didactics, and team learning with a card game simulating the use of the SPRINT tool on a shift. Residents were surveyed to evaluate their task-management confidence and perceived effectiveness of the curriculum.

RESULTS

A total of 34 EM residents participated in this training on the SPRINT tool. There was an improvement in resident confidence in task management, and residents reporting having a strategy for task prioritization 8 weeks after the workshop.

DISCUSSION

The SPRINT curriculum provides EM residents with a tool to manage the complex task-management environment of the ED. Further research in task-management education should focus on patient-oriented outcomes among physicians who have received this training.

Examining the association of career stage and medical specialty with personality preferences - a cross-sectional survey of junior doctors and attending physicians from various specialties

BACKGROUND

Personality preference research on medical students and physicians demonstrates that personality preferences may affect one's choice of specialty and transform over the course of one's academic career as well as during one's time spent in the clinical setting. The literature offers valuable methods for evaluating medical curricula, understanding medical specialties, and rethinking communication techniques between educators and learners. In line with this encompassing body of work, this study examines the personality preferences of junior doctors and attending physicians from various specialties to investigate how career stage and medical specialty are associated with personality preferences.

METHOD

The Myers-Briggs Type Indicator (MBTI) was applied to assess the personality preferences of junior doctors (postgraduates year 1-3) and attending physicians from six major medical specialties. Participants completed a self-administered 93-item questionnaire, while a certified MBTI practitioner explained the personality dichotomies as well as facilitated the self-evaluation process and the questionnaire's interpretation. Contrasted dichotomous scores and radar plots were employed to illustrate the distinction between junior doctors and attending physicians' personality preferences. All analyses were performed using the SAS statistical software, while a Wilcoxon rank-sum test was used to quantify the polarisation of personality preferences between junior doctors and attending physicians.

RESULTS

In total, 98 participants were recruited, of whom 59 were attending physicians and 39 were junior doctors. The most common personality types among the junior doctors were ESTJ (15.4%), INTP (12.8%), and ESFJ (10.3%), while among the attending physicians, the most common types were ISTJ (23.7%) and ESTJ (18.6%). Both junior doctors and attending physicians expressed personality preferences for sensing, thinking, and judging. However, compared to the junior doctors, more polarised personality preferences were noted among the attending physicians for sensing (p = 0.038), thinking (p = 0.032), and judging (p = 0.024). Moreover, junior doctors exhibited less distinct personality preferences in this study.

CONCLUSION

Attending physicians and junior doctors exhibited greater personality inclinations for sensing, thinking, and judging, although the former expressed these personality preferences more strongly than the latter. These findings highlight that, amongst physicians, career stage is strongly associated with the expression of personality preferences.

Visualising clinical work in the emergency department: Understanding interleaved patient management

We present a unique data visualisation approach, called workflow time charts, to illustrate the sequential and multi-dimensional nature of work in emergency departments. Using 40 h of data from direct observations of emergency physicians, we applied the charts to visualise patient-stratified physicians' work as a continuous temporal process, including distinguishing tasks of different types and representing external prompts (similar to interruptions) and multitasking performance. The charts showed frequent changes in the nature of observed activities, with interleaved multitasking a constant feature and external prompts often clustered in time. Evidence of seniority-related differences in work were apparent with consultants switching between more concurrent patients and receiving more frequent clinical prompts than junior physicians, illustrating their overseeing and advice-giving role. The ubiquity of interleaved multitasking suggests a need to focus on developing individual strategies to support frequent cognitive switching. Work that appears fragmented at physician level may form part of a flexible and robust system, rather than an error-prone set of isolated individual behaviours.

Impact of Electronic Health Record Implementation on Ophthalmology Trainee Time Expenditures

Objective

Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation.

Design

Prospective, manual time-motion observations of ophthalmology trainees in 2018.

Participants

Eleven ophthalmology residents and fellows observed during 156 patient encounters.

Methods

Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models.

Main Outcome Measures

Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients.

Results

Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; p = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; p = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; p = 0.011).

Conclusion

Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout.

Asteroids® and Electrocardiograms: Proof of Concept of a Simulation for Task-Switching Training

Introduction

Emergency physicians are interrupted during patient care with such tasks as reading electrocardiograms (ECGs). This phenomenon is known as task-switching which may be a teachable skill. Our objective was to evaluate the potential of a video game for simulating the cognitive demands required of task-switching.

Methods

Emergency medicine residents took a pretest on ECG interpretation and then a posttest while attending to a video game, Asteroids®.

Results

The 35 residents (63%) who participated, scored worse on the ECG posttest then they did on the pretest (p<.001; effect size=1.14). There were no differences between genders or training level.

Conclusion

Interpreting ECGs while playing the Asteroids® game significantly lowered ECG interpretation scores. This shows the potential of this activity for training residents in task-switching ability. The next phase of research will test whether ECG reading performance while task-switching improves with practice.

Development of a Clinical Teaching Evaluation and Feedback Tool for Faculty

Introduction

Formative evaluations of clinical teaching for emergency medicine (EM) faculty are limited. The goal of this study was to develop a behaviorally-based tool for evaluating and providing feedback to EM faculty based on their clinical teaching skills during a shift.

Methods

We used a three-phase structured development process. Phase 1 used the nominal group technique with a group of faculty first and then with residents to generate potential evaluation items. Phase 2 included separate focus groups and used a modified Delphi technique with faculty and residents, as well as a group of experts to evaluate the items generated in Phase 1. Following this, residents classified the items into novice, intermediate, and advanced educator skills. Once items were determined for inclusion and subsequently ranked they were built into the tool by the investigators (Phase 3).

Results

The final instrument, the “Faculty Shift Card,” is a behaviorally-anchored evaluation and feedback tool used to facilitate feedback to EM faculty about their teaching skills during a shift. The tool has four domains: teaching clinical decision-making; teaching interpersonal skills; teaching procedural skills; and general teaching strategies. Each domain contains novice, intermediate, and advanced sections with 2–5 concrete examples for each level of performance.

Conclusion

This structured process resulted in a well-grounded and systematically developed evaluation tool for EM faculty that can provide real-time actionable feedback to faculty and support improved clinical teaching.

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study

BACKGROUND

Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals' task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied.

OBJECTIVE

To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors.

METHODS

36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians' working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep.

RESULTS

Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.

CONCLUSION

Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments.

Emotional intelligence, perceived stress and academic performance of Sri Lankan medical undergraduates

BACKGROUND

Previous research has shown that higher Emotional Intelligence (EI) is associated with better academic and work performance. The present study intended to explore the relationship between EI, perceived stress and academic performance and associated factors among medical undergraduates.

METHODS

This descriptive cross-sectional research study was conducted among 471 medical undergraduates of 2nd, 4th and final years of University of Colombo, Sri Lanka. Students were rated on self administered Perceived Stress Scale (PSS) and Schutte Self-Report Emotional Intelligence Test (SEIT). Examination results were used as the dichotomous outcome variable in a logistic regression analysis.

RESULTS

Females had higher mean EI scores (p = 0.014). A positive correlation was found between the EI score and the number of extracurricular activities (r = 0.121, p = 0.008). Those who were satisfied regarding their choice to study medicine, and who were planning to do postgraduate studies had significantly higher EI scores and lower PSS scores (p <0.001). Among final year undergraduates, those who passed the Clinical Sciences examination in the first attempt had a higher EI score (p <0.001) and a lower PSS score (p <0.05). Results of the binary logistic-regression analysis in the entire study population indicated that female gender (OR:1.98) and being satisfied regarding their choice of the medical undergraduate programme (OR:3.69) were significantly associated with passing the examinations. However, PSS Score and engagement in extracurricular activities were not associated with 'Examination Results'.

CONCLUSIONS

Higher EI was associated with better academic performance amongst final year medical students. In addition a higher EI was observed in those who had a higher level of self satisfaction. Self-perceived stress was lower in those with a higher EI. Enhancing EI might help to improve academic performance among final year medical student and also help to reduce the stress levels and cultivate better coping during professional life in the future.

Multitasking simulation: Present application and future directions

The Accreditation Council for Graduate Medical Education lists multi-tasking as a core competency in several medical specialties due to increasing demands on providers to manage the care of multiple patients simultaneously. Trainees often learn multitasking on the job without any formal curriculum, leading to high error rates. Multitasking simulation training has demonstrated success in reducing error rates among trainees. Studies of multitasking simulation demonstrate that this type of simulation is feasible, does not hinder the acquisition of procedural skill, and leads to better performance during subsequent periods of multitasking. Although some healthcare agencies have discouraged multitasking due to higher error rates among multitasking providers, it cannot be eliminated entirely in settings such as the emergency department in which providers care for more than one patient simultaneously. Simulation can help trainees to identify situations in which multitasking is inappropriate, while preparing them for situations in which multitasking is inevitable.

Four Successive Years of Trauma-Based Objective Structured Clinical Evaluations: What Have We Learned?

OBJECTIVE

We studied 4 years of data from our objective structured clinical examination (OSCE) to determine whether residents improved skills in the trauma physical examination (PE). Our hypothesis was that residents would improve with each year of training, and that resident scores would also improve over time, with each year of OSCE testing.

DESIGN

We developed 2 polytrauma scenarios and alternated yearly. Residents were graded on PE, history taking, and professionalism. Scenarios simulated trauma cases residents could encounter during training. We compared each year for any significant (p < 0.05) changes overall and between postgraduate years.

SETTING

The Ohio State University Wexner Medical Center.

PARTICIPANTS

Orthopedic faculty and residents.

RESULTS

Across years 2010 to 2013, we saw no significant improvement in PE skills. History-taking skills trended upwards, but this was not significant, and communication skills significantly improved.

CONCLUSIONS

We expected after instituting a trauma OSCE that we would see an improvement in residents' PE skills, which we did not. We observed an overall improvement in ability to interact and communicate with patients and ask appropriate questions.

Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine

Emergency physicians work in a fast-paced environment that is characterized by frequent interruptions and the expectation that they will perform multiple tasks efficiently and without error while maintaining oversight of the entire emergency department. However, there is a lack of definition and understanding of the behaviors that constitute effective task switching and multitasking, as well as how to improve these skills. This article reviews the literature on task switching and multitasking in a variety of disciplines-including cognitive science, human factors engineering, business, and medicine-to define and describe the successful performance of task switching and multitasking in emergency medicine. Multitasking, defined as the performance of two tasks simultaneously, is not possible except when behaviors become completely automatic; instead, physicians rapidly switch between small tasks. This task switching causes disruption in the primary task and may contribute to error. A framework is described to enhance the understanding and practice of these behaviors.