Sharma S. A Single-Blinded, Direct Observational Study of PGY-1 Interns and PGY-2 Residents in Evaluating their History-Taking and Physical-Examination Skills. The Permanente Journal. 2011;15(4).
The hospital can be a very scary place, and when I read this study, I immediately thought that it would bring to life the worst fears of our patients, their families, and their doctors too.
The paper describes structured observations of PGY-1 and PGY-2 (first and second year out of medical school physicians-in-training) doing initial history and physical examinations of patients in the hospital.
As the title says, the study was “single-blinded” – the physicians observed did not know what they were being observed for, just that they were being observed (consent was obtained from both the patients and the physicians).
And… while patients were asked 100% of the time what medications they were taking (score for medication reconciliation), they were asked what they did for a living 4% of the time, level of education 0 % of the time, and from 0 to 100% of a list of other important pieces of information. Same general trends were seen in physical exam performance. Take a look at the charts by clicking on the link above and see what thing you would want your doctor to know if you were put in the hospital wasn’t asked.
Average time observed doing physicals and history: 7.3 minutes for history, 5.29 minutes for physicals, average time claimed in a survey of the doctors: 28 minutes and 15 minutes respectively . Huge discrepancy.
36% of the time, the physicians did not introduce themselves to the patient.
72% of the time, the physicians did not explain what they were there to do.
Remember, this is admission to the hospital.
“Unclear what the most effective approach would be to change these behaviors”
This is the ominous sounding statement made in the discussion by the author, who appropriately conveys his dissatisfaction with these results, and the fact that the physicians have been taught what the right things are to do.
From my own experience, I believe him. The issue isn’t knowing what to do. In my own training, I didn’t explore the patient and family experience as much as I should have. My residency faculty really helped me with that. At the same time, they were under tremendous pressure to balance educational requirements, the needs of patients getting care, and the needs of their fellow physicians and nurses that they recruited to participate in our teaching. Sometimes this balance was not balanced in a stressful environment.
Could we recruit patients and families also?
As much as we recruit quality faculty to teach residents, couldn’t we recruit patients and families, too?
It’s a familiar experience after a resident takes care of a patient in the hospital to be asked by the patient if they can join the resident’s practice. What would it be like if each resident needed to recruit 1-3 patients that they took care of to become part of THEIR (the resident’s) care team? Imagine them asking one of their patients or their family on discharge, “Mrs. Smith, as part of my training, I need to have 3 patient advisors who will help supervise my training, would you be available?”
Interestingly, an example of the clarity that patients bring to a physician’s development at any stage of practice-life comes in the same issue of The Permanente Journal, from a patient with an adverse outcome (“Bridging Physician-Patient Perspectives Following an Adverse Medical Outcome“
Until my mother went through this experience, it never occurred to me how much medical professionals ask of us. Our family was asked to entrust the care of our loved one to strangers, her life and health to a system that sometimes creates barriers for the sake of efficiency. Then in the face of an error we are expected to stay quiet and accept this devastating impact on our loved one.
This article speaks about the HealthCare Ombudsman/Mediator Program at Kaiser Permanente, which brings patients and physicians together to resolve communication, quality, and trust issues. In the same article, a physician who discloses a surgical error carefully to a patient and their family says:
This process of explaining myself, opening me up to colleague scrutiny and patient disappointment, was by no means easy. Nevertheless, I know the price paid was infinitely less than living with the thought I had caused harm to a patient and did nothing to remedy it with a truthful disclosure and a heartfelt apology.
Thereafter, I followed-up with my patient and her family, explaining the systemic changes made to prevent a wrong part from ever being introduced during a surgical procedure.
Could some of these people, during and after their healing, serve as advisors/coaches/guardian angels of our future physicians as they learn their craft? They (the patients) are who I see as my guardian angels today – this just speeds up that journey.
Is this farfetched, is this happening somewhere already? What are the nuances? Please post in the comments
It is critical that the healthcare industry embrace a more sustainable culture of truth. The current entitlement culture is producing patient harm that our nation cannot pay for and trust is broken. Our health is not dependent upon the doctor pretending to be a perfect human being (God). Admitting mistakes allows mistakes to be corrected so that others are not hurt and harmed patients to be cared for and perhaps apologized to and compensated.
@JjrkCh Thank you for your comment, it reinforces what I like to say, that “patients don’t expect us to be perfect, they expect us to fix our mistakes quickly.” To do that requires acknowledgement of errors and a commitment to prevent them from happening again. From the example above, it seems that when patients and physicians talk about this, they both understand the need well. The opportunity I think is for them to not have to wait until an adverse avent happens to come together,
Yikes! What physicians in training don’t ask patients admitted to the hospital Yikes! http://t.co/TBKCSEa3 by @tedeytan
Yikes! What physicians in-training don’t ask patients admitted to the hospital via @TedEytan http://t.co/rqyP9rZK #healthcare