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Quintero D, Reinoso Chávez N N, Vallejo J. Learning to Communicate: A Photovoice Study With Intensive Care Residents During Night Shifts in the Intensive Care Unit. QUALITATIVE HEALTH RESEARCH 2024; 34:783-797. [PMID: 38238935 DOI: 10.1177/10497323231222388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
This study explored the learning experiences of intensive care residents in an intensive care unit (ICU) during night shifts and the development of communication skills in this community of practice. This action research qualitative study used the photovoice method in four workshops. A group of nine residents shared their learning experiences and collectively analyzed, built, and presented proposals to improve residents' communication skills in the community of practice in which they become intensivists. Participatory thematic analysis was conducted. Students concluded that night shifts in the ICU offered a perfect situational learning environment for communication with one-on-one resident-teacher relationships, less administrative work, and more resident responsibility, improving intensivist identity. Role models, reflective thinking, and teamwork are essential for fostering communication skills among intensivist community members and are all trainable. The results and student suggestions were presented to teachers and decision-makers in the clinic. These photovoice strategies developed students' abilities to share their critical views and suggestions with decision-makers for subsequent implementation, enhancing their confidence in their learning process, strengthening trust-based relationships with teachers, and improving future intensivists' practice communities.
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Affiliation(s)
- Diana Quintero
- Medical Education, Universidad de La Sabana, Chía, Colombia
| | | | - Juliana Vallejo
- Medical Education Department, Universidad de La Sabana, Chía, Colombia
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Herzog TL, Sawatsky AP, Kelm DJ, Nelson DR, Park JG, Niven AS. The Resident Learning Journey in the Medical Intensive Care Unit. ATS Sch 2023; 4:177-190. [PMID: 37533538 PMCID: PMC10391714 DOI: 10.34197/ats-scholar.2022-0103oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/27/2023] [Indexed: 08/04/2023] Open
Abstract
Background The medical intensive care unit (MICU) offers rich resident learning opportunities, but traditional teaching strategies can be difficult to employ in this fast-paced, high-acuity environment. Resident perspectives of learning within this environment may improve our understanding of the common challenges residents face and inform novel approaches to transform the MICU educational experience. Objective We conducted a qualitative study of internal medicine residents to better understand their approach to learning the critical care activities that they are entrusted to perform in the MICU. Methods Using a thematic analysis approach, we conducted six focus group interviews with 15 internal medicine residents, separated by postgraduate year. A trained investigator led each interview, which was audio-recorded and transcribed verbatim for analysis. Our diverse research team, representing different career stages across the continuum of learning to minimize interpretive bias, identified codes and subsequent themes inductively. We refined these themes through group discussion and sensitizing social learning theory concepts using Wenger's community of practice and organized them to create learner archetypes and a conceptual framework of resident learning in the MICU. Results We identified three thematic resident learning categories: learning goals and motivation, clinical engagement, and interprofessional collaboration. We distinguished three learner archetypes, the novice, experiential learner, and practicing member, to describe progressive resident development within the interprofessional MICU team, the challenges they frequently encounter, and potential teaching strategies to facilitate learning. Conclusion We developed a conceptual framework that describes the resident's journey to becoming a trusted, collaborating member of the interprofessional MICU team. We identified common developmental challenges residents face and offer educational strategies that may support their progress. These findings should inform future efforts to develop novel teaching strategies to promote resident learning in the MICU.
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Affiliation(s)
| | - Adam P. Sawatsky
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Diana J. Kelm
- Division of Pulmonary and Critical Care Medicine and
| | | | - John G. Park
- Division of Pulmonary and Critical Care Medicine and
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Kahn JM, Yabes JG, Bukowski LA, Davis BS. Intensivist physician-to-patient ratios and mortality in the intensive care unit. Intensive Care Med 2023; 49:545-553. [PMID: 37133740 PMCID: PMC10155655 DOI: 10.1007/s00134-023-07066-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients. METHODS We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days. RESULTS The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14). CONCLUSIONS Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States.
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Affiliation(s)
- Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA.
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, 15213, USA.
| | - Jonathan G Yabes
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Leigh A Bukowski
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
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Doyle S, Sharp M, Winter G, Khan MMKS, Holden R, Djondo D, Bosslet G, Lenz P. Twelve tips for teaching in the ICU. MEDICAL TEACHER 2021; 43:1005-1009. [PMID: 33563060 DOI: 10.1080/0142159x.2020.1859097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The intensive care unit (ICU) provides unique educational opportunities for both undergraduate and postgraduate learners, including procedural training, ventilator management guidance, complex communication scenarios, and didactic lectures on dynamic topics like multi-system organ failure. However, certain challenges are inherent in this setting that can make teaching difficult. Different trainee educational backgrounds, variability in disease states, time limitations and urgent patient care considerations highlight some challenges that limit teaching opportunities. The following twelve tips address these unique aspects of the ICU environment and provide strategies to optimize teaching. These tips focus on three main goals: creating an optimal learning environment, increasing learner engagement, and critically challenging learners.
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Affiliation(s)
- Stephen Doyle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Spectrum Health, Grand Rapids, MI, USA
| | - Michelle Sharp
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gretchen Winter
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Malik M Khurram S Khan
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY, USA
| | - Rhiannon Holden
- Division of Pulmonary and Critical Care Medicine, WellStar Medical Group, Smyrna, GA, USA
| | - Daniel Djondo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Suburban Lung Associates in Elk Grove, IL, USA
| | - Gabriel Bosslet
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Indiana University, Indianapolis, IN, USA
| | - Peter Lenz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Assessment of Gender-based Qualitative Differences within Trainee Evaluations of Faculty. Ann Am Thorac Soc 2021; 17:621-626. [PMID: 31821770 DOI: 10.1513/annalsats.201906-479oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Recent studies of trainee evaluations of medical faculty have demonstrated subtle gender-based word choice differences. However, it is not known if this manifests in major contextual differences in written comments.Objectives: To characterize qualitative differences in narrative evaluations of female and male pulmonary and critical care medicine faculty.Methods: We performed a single-center, retrospective cohort analysis of trainee narrative evaluations of pulmonary and critical care medicine faculty at the Hospital of the University of Pennsylvania, written from 2015 to 2016. Directive and summative content analysis was performed by four raters. Major contextual themes were identified using constant comparative techniques. Thematic differences based on faculty gender were identified, with statistical significance determined using χ2 analysis (P < 0.05). Effect sizes were calculated using Cramér's V.Results: A total of 1,216 total narrative evaluations were analyzed, representing 62 faculty members (17 women and 45 men), with analysis continued for the full cohort beyond achieving saturation of themes. Five overarching themes emerged: teaching skills, clinical skills, supervision, interpersonal and communication skills, and leadership skills. Within subthemes, we found no significant gender differences in reference to general teaching skills, learning environment, enthusiasm for teaching, or interpersonal concern. We identified subtheme differences between male and female faculty evaluations in regard to mentions of learner autonomy, clinical learning environment, humor, and motivating the trainee for patient care. Although the mention of constructive criticisms did not differ between genders, constructive criticisms of female faculty were more likely to mention demeanor (P = 0.06).Conclusions: Our data suggest minimal thematic differences in trainee narrative evaluations of male and female pulmonary and critical care medicine faculty. However, we noted several subtheme contextual differences between male and female faculty, which warrants further investigation.
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Reducing Diagnostic Error in the Intensive Care Unit. Engaging Uncertainty When Teaching Clinical Reasoning. ATS Sch 2020; 1:364-371. [PMID: 33870307 PMCID: PMC8015765 DOI: 10.34197/ats-scholar.2020-0043ps] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
As medicine continues to advance with improvements in technology, factual information has become more easily available at the bedside. Nevertheless, diagnostic error remains a salient concern for the medical community and public. To address this problem, two fundamental characteristics of the physician remain important: curiosity and the ability to apply critical reasoning to solve problems, often in the setting of imperfect knowledge and uncertainty. Historically, the teaching and recall of factual information, illness scripts, and pattern recognition are emphasized early in medical education. Students are often left with the impression that there is a single correct answer for every question; discussions of uncertainty are rare. Consequently, discomfort with uncertainty is common among doctors. As attention to explicit teaching of clinical reasoning increases, one must consider how to incorporate uncertainty into that teaching and to transform the clinical learning environment to embrace uncertainty. The authors propose the use of several simple methods easily employed in the critical care setting to make uncertainty explicit by changing the language used for expressing differential diagnosis, incorporating probabilities into daily sign-outs, and by implementing inductive reasoning when teaching critical thinking to offer learners a strategy for working through unknown problems; these approaches may normalize uncertainty, improve comfort with it, and reduce the impact of cognitive bias in decision-making. Comfort with uncertainty may result not only in improved clinical experiences for learning by transforming a once negative cognitive experience to a positive one but also in reduced susceptibility to thinking errors.
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Petri CR, Anandaiah A, Schwartzstein RM, Hayes MM. Enhancing teaching and learning in the ICU. CLINICAL TEACHER 2019; 17:464-470. [PMID: 31869526 DOI: 10.1111/tct.13126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Camille R Petri
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Asha Anandaiah
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard M Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Carl J Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Carl J Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Santhosh L, Brown W, Ferreira J, Niroula A, Carlos WG. Practical Tips for ICU Bedside Teaching. Chest 2019; 154:760-765. [PMID: 30290929 DOI: 10.1016/j.chest.2018.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/02/2018] [Accepted: 06/25/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lekshmi Santhosh
- Department of Medicine, University of California-San Francisco, San Francisco, CA.
| | - Wade Brown
- Department of Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Juliana Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - W Graham Carlos
- Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
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