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Emergency Medicine Australasia (2014) 26, 303–304
doi: 10.1111/1742-6723.12234
PERSPECTIVE
Remember that patient you saw last week? Stephen GILDFIND,1 Diana EGERTON-WARBURTON1,2 and Simon CRAIG1,2 1 Emergency Department, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia, and 2Southern Clinical School, Monash University, Melbourne, Victoria, Australia
Abstract Patient outcome feedback has been defined as ‘the natural process of finding out what happens to one’s patients after their evaluation and treatment (in the ED)’. It seems likely that emergency medicine trainees and Fellows will improve their diagnostic accuracy if they increase the frequency with which they find out what happens to their patients. Not only does this allow testing of their own diagnosis with the final diagnosis, but also allows meaningful feedback on therapies commenced in the ED. We believe that seeking outcome feedback should be more actively encouraged by the ACEM training programme. Key words: diagnostic error, emergency medicine, follow-up, outcome feedback, training.
Case 1 A 55-year-old woman presents with knee pain after a fall. Examination suggests the need for an X-ray, although you have a low clinical suspicion. An X-ray is ordered; however, you do not detect a fracture. The patient is sent home with crutches and advice on managing her soft tissue injury.
Case 2 He steadies himself, taking a few deep breaths. He checks the wind direction and focuses on the goals – 45 m away,
past his opponent standing on the mark. He is momentarily distracted by the sound of the final siren. Socks are adjusted. Steadily, he approaches, leans back and kicks the ball . . . The patient has left the department. The ball has left the boot. What happens next? How will we find out? Is Aussie Rules more important than emergency medicine (EM)? EM training in Australasia is a long and intensive process, lasting a minimum of 7 years after medical school graduation. Many trainees take longer than this, with a maximum time allowed of 15 years.1 To become an emergency physician, trainees must acquire a breadth of knowledge across many fields, as well as various procedural, management, interpersonal and communication skills.1 Given the challenges of the training programme, the efficiency of this process should be optimised. It is in the best interests of patients, trainees and emergency physicians that the training programme be as effective and efficient as possible. Currently, the training programme is undergoing a comprehensive restructure under the banner of the ‘Curriculum Review Project’. Several new initiatives are to be commended, including the introduction of workplacebased assessments, and revision of the Fellowship examination. We propose that EM training could be further improved through structured utilisation
Correspondence: Dr Stephen Gildfind, Emergency Department, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia. Email: gildfind@ gmail.com Stephen Gildfind, MBBS (Hons), MPH (Harvard), BA, Emergency Registrar; Diana Egerton-Warburton, MBBS, FACEM, MClinEpi, Emergency Physician, Director of EM Research, Adjunct Senior Lecturer; Simon Craig, MBBS (Hons), FACEM, MHPE, Emergency Physician, Director of Emergency Medicine Training, Adjunct Senior Lecturer. Accepted 25 February 2014
of patient ‘outcome feedback’, to improve knowledge and reduce diagnostic error. It is our contention that learning what ultimately happens to one’s patients might serve as a highyield, time-efficient element of EM training, which should be more actively harnessed. The occurrence of medical errors is an area of concern to the community. Emergency doctors assess a patient in the ED and formulate a working diagnosis. Although diagnostic error is inevitable, we should ensure that our training programme has been designed to minimise it. Although a significant proportion of diagnostic error goes unreported,2 EM doctors understand the potential danger of misdiagnosis. A survey exploring resident perception of medical ‘mishaps’ in the USA demonstrated diagnostic errors to be a dominant concern.3 Factors contributing to diagnostic error include a wide range of cognitive errors, misinterpretation of diagnostic imaging, atypical presentations of relatively common conditions and failure to pay attention to abnormal test results.2–4 Where other industries view error as inevitable, errors are relatively stigmatised in medicine. Indeed, it has been hypothesised that this tendency might originate from the Hippocratic Oath, ‘Above all do no harm’, such that errors in diagnosis and/or management are frequently viewed as failures on behalf of the clinician.5 EM is a specialty that routinely subjects individuals to high workloads, multiple interruptions and time-pressured decision-making – all increasing the likelihood of error. Croskerry’s paper, ‘The Feedback Sanction’, illustrates barriers impeding an EM practitioner’s ability to find out what ultimately happens to his or her patients. These include delay between ED assessment and the ultimate outcome, poor information
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
304
S GILDFIND ET AL.
reporting systems, workload and time pressures that discourage proactive attainment of outcome information, and shift work.6 Previous work suggests diagnostic errors detected after admission are rarely communicated to the emergency physician.3 Cases leaving the ED ‘Not Yet Diagnosed’ could prove particularly informative.6 The term ‘outcome feedback’ was more formally defined by Lavoie and colleagues as ‘the natural process of finding out what happens to one’s patients after their evaluation and treatment in the (ED)’. 7 The authors highlight the relatively sparse research in this field, suggesting further work is required to determine: • The severity of Croskerry’s ‘Feedback Sanction’ • Whether increasing outcome feedback yields anticipated educational benefits • Whether increasing outcome feedback might improve ED care. Within the world of medicine, this problem of rarely seeing your patient again is infrequently encountered in other specialties. A survey of Canadian emergency physicians found that passive outcome feedback (e.g. an outpatient consultation reply, or a copy of the patient’s discharge summary) occurred in a median of 10% of cases, whereas feedback was actively sought by the emergency doctor in a median of 5% of cases.8 Although this might not be directly translatable to the Australian setting, we have little reason to believe that things are much different. In the process of learning to shoot a basketball, if one were to close one’s eyes 90% of the time, and not know whether the target had been met, this would probably be detrimental to the learning process, and to the attainment of skill. Although this analogy is of course an over-simplification, it seems likely a similar mechanism must occur for learning and improving as an EM clinician. Smith’s article ‘To Keep An Incessant Watch’ describes one EM trainee’s rigorous attempt at obtaining maximal patient outcome feedback. His insights, although not necessarily generalisable, are very interesting. For example, he came to appreciate the risks associated with clinical handover, and of neglecting important test
results for patients admitted under an inpatient unit. He emphasises that continuing to attain this outcome feedback assists more advanced clinicians to avoid a plateau in their learning.9 There are other potential advantages to seeking out outcome feedback: • Analysing a single adverse event or near miss can serve as a valuable learning exercise3 • High-risk patients followed up soon after discharge from the ED might have decreased adverse outcomes4 • Identification of the deteriorating discharged patient, provision of opportunities for the patient to ask further questions and cultivation of good public relations.10 The importance of attaining outcome feedback has been acknowledged in the United States EM training programme. There is, however, persistent suboptimal compliance with this training requirement.10 One might expect, therefore, that in Australia and New Zealand, where there is less emphasis on outcome feedback, compliance with such practices will also be poor. In the Australasian setting, we propose that our training programme should actively encourage emergency clinicians to seek outcome feedback. We believe that seeking outcome feedback should become a training requirement. This could be supported by designated and protected time for trainees to read discharge summaries, follow-up investigation results and contact patients. To be able to improve our practice, it is crucial we are aware of the outcomes of our work. By making outcome feedback part of the regular workflow for emergency trainees (and Fellows), we might be able to disrupt, or at least circumvent, the feedback sanction.
Case 1 You review the notes a week later. The patient returned 4 days after her original presentation with persistent knee pain and a CT scan demonstrated a tibial plateau fracture. You check the initial X-ray and now notice a subtle fracture line.
Case 2 Who cares? It’s just a game, isn’t it?
Author contributions SG: concept, literature review, manuscript preparation; DE-W: concept, manuscript preparation; SC: literature review, manuscript preparation.
Competing interests DE-W is a section editor for Emergency Medicine Australasia.
References 1. Australian College of Emergency Medicine training manual. [Cited 12 Jul 2013.] Available from URL: http:// acem.org.au 2. Kuhn GJ. Diagnostic errors. Acad. Emerg. Med. 2002; 9: 740–50. 3. Schenkel SM, Khare RK, Rosenthal MM, Sutcliffe KM, Lewton EL. Resident perceptions of medical errors in the emergency department. Acad. Emerg. Med. 2003; 10: 1318–24. 4. Chern C-H, How C-K, Wang L-M, Lee C-H, Graff L. Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes. Ann. Emerg. Med. 2005; 45: 15–23. 5. Hobgood CD, Ma OJ, Swart GL. Emergency medicine resident errors identification and educational utilization. Acad. Emerg. Med. 2000; 7: 1317–20. 6. Croskerry P. The feedback sanction. Acad. Emerg. Med. 2000; 7: 1232–8. 7. Lavoie CF, Schachter H, Stewart AT, McGowan J. Does outcome feedback make you a better emergency physician? A systematic review and research framework proposal. CJEM 2009; 11: 545–52. 8. Lavoie CF, Plint AC, Clifford TJ, Gaboury I. ‘I never hear what happens, even if they die’: a survey of emergency physicians about outcome feedback. CJEM 2009; 11: 523–8. 9. Smith KA. To keep an incessant watch. Acad. Emerg. Med. 2011; 18: 545–8. 10. Gaeta TJ, Osborn HH. Increasing compliance with the residency review committee requirements for followup in academic emergency departments. Emergency Medicine Follow-up Study Group. Ann. Emerg. Med. 1999; 33: 510–5.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2014) 26, 303–304
doi: 10.1111/1742-6723.12234
PERSPECTIVE
Remember that patient you saw last week? Stephen GILDFIND,1 Diana EGERTON-WARBURTON1,2 and Simon CRAIG1,2 1 Emergency Department, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia, and 2Southern Clinical School, Monash University, Melbourne, Victoria, Australia
Abstract Patient outcome feedback has been defined as ‘the natural process of finding out what happens to one’s patients after their evaluation and treatment (in the ED)’. It seems likely that emergency medicine trainees and Fellows will improve their diagnostic accuracy if they increase the frequency with which they find out what happens to their patients. Not only does this allow testing of their own diagnosis with the final diagnosis, but also allows meaningful feedback on therapies commenced in the ED. We believe that seeking outcome feedback should be more actively encouraged by the ACEM training programme. Key words: diagnostic error, emergency medicine, follow-up, outcome feedback, training.
Case 1 A 55-year-old woman presents with knee pain after a fall. Examination suggests the need for an X-ray, although you have a low clinical suspicion. An X-ray is ordered; however, you do not detect a fracture. The patient is sent home with crutches and advice on managing her soft tissue injury.
Case 2 He steadies himself, taking a few deep breaths. He checks the wind direction and focuses on the goals – 45 m away,
past his opponent standing on the mark. He is momentarily distracted by the sound of the final siren. Socks are adjusted. Steadily, he approaches, leans back and kicks the ball . . . The patient has left the department. The ball has left the boot. What happens next? How will we find out? Is Aussie Rules more important than emergency medicine (EM)? EM training in Australasia is a long and intensive process, lasting a minimum of 7 years after medical school graduation. Many trainees take longer than this, with a maximum time allowed of 15 years.1 To become an emergency physician, trainees must acquire a breadth of knowledge across many fields, as well as various procedural, management, interpersonal and communication skills.1 Given the challenges of the training programme, the efficiency of this process should be optimised. It is in the best interests of patients, trainees and emergency physicians that the training programme be as effective and efficient as possible. Currently, the training programme is undergoing a comprehensive restructure under the banner of the ‘Curriculum Review Project’. Several new initiatives are to be commended, including the introduction of workplacebased assessments, and revision of the Fellowship examination. We propose that EM training could be further improved through structured utilisation
Correspondence: Dr Stephen Gildfind, Emergency Department, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia. Email: gildfind@ gmail.com Stephen Gildfind, MBBS (Hons), MPH (Harvard), BA, Emergency Registrar; Diana Egerton-Warburton, MBBS, FACEM, MClinEpi, Emergency Physician, Director of EM Research, Adjunct Senior Lecturer; Simon Craig, MBBS (Hons), FACEM, MHPE, Emergency Physician, Director of Emergency Medicine Training, Adjunct Senior Lecturer. Accepted 25 February 2014
of patient ‘outcome feedback’, to improve knowledge and reduce diagnostic error. It is our contention that learning what ultimately happens to one’s patients might serve as a highyield, time-efficient element of EM training, which should be more actively harnessed. The occurrence of medical errors is an area of concern to the community. Emergency doctors assess a patient in the ED and formulate a working diagnosis. Although diagnostic error is inevitable, we should ensure that our training programme has been designed to minimise it. Although a significant proportion of diagnostic error goes unreported,2 EM doctors understand the potential danger of misdiagnosis. A survey exploring resident perception of medical ‘mishaps’ in the USA demonstrated diagnostic errors to be a dominant concern.3 Factors contributing to diagnostic error include a wide range of cognitive errors, misinterpretation of diagnostic imaging, atypical presentations of relatively common conditions and failure to pay attention to abnormal test results.2–4 Where other industries view error as inevitable, errors are relatively stigmatised in medicine. Indeed, it has been hypothesised that this tendency might originate from the Hippocratic Oath, ‘Above all do no harm’, such that errors in diagnosis and/or management are frequently viewed as failures on behalf of the clinician.5 EM is a specialty that routinely subjects individuals to high workloads, multiple interruptions and time-pressured decision-making – all increasing the likelihood of error. Croskerry’s paper, ‘The Feedback Sanction’, illustrates barriers impeding an EM practitioner’s ability to find out what ultimately happens to his or her patients. These include delay between ED assessment and the ultimate outcome, poor information
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
304
S GILDFIND ET AL.
reporting systems, workload and time pressures that discourage proactive attainment of outcome information, and shift work.6 Previous work suggests diagnostic errors detected after admission are rarely communicated to the emergency physician.3 Cases leaving the ED ‘Not Yet Diagnosed’ could prove particularly informative.6 The term ‘outcome feedback’ was more formally defined by Lavoie and colleagues as ‘the natural process of finding out what happens to one’s patients after their evaluation and treatment in the (ED)’. 7 The authors highlight the relatively sparse research in this field, suggesting further work is required to determine: • The severity of Croskerry’s ‘Feedback Sanction’ • Whether increasing outcome feedback yields anticipated educational benefits • Whether increasing outcome feedback might improve ED care. Within the world of medicine, this problem of rarely seeing your patient again is infrequently encountered in other specialties. A survey of Canadian emergency physicians found that passive outcome feedback (e.g. an outpatient consultation reply, or a copy of the patient’s discharge summary) occurred in a median of 10% of cases, whereas feedback was actively sought by the emergency doctor in a median of 5% of cases.8 Although this might not be directly translatable to the Australian setting, we have little reason to believe that things are much different. In the process of learning to shoot a basketball, if one were to close one’s eyes 90% of the time, and not know whether the target had been met, this would probably be detrimental to the learning process, and to the attainment of skill. Although this analogy is of course an over-simplification, it seems likely a similar mechanism must occur for learning and improving as an EM clinician. Smith’s article ‘To Keep An Incessant Watch’ describes one EM trainee’s rigorous attempt at obtaining maximal patient outcome feedback. His insights, although not necessarily generalisable, are very interesting. For example, he came to appreciate the risks associated with clinical handover, and of neglecting important test
results for patients admitted under an inpatient unit. He emphasises that continuing to attain this outcome feedback assists more advanced clinicians to avoid a plateau in their learning.9 There are other potential advantages to seeking out outcome feedback: • Analysing a single adverse event or near miss can serve as a valuable learning exercise3 • High-risk patients followed up soon after discharge from the ED might have decreased adverse outcomes4 • Identification of the deteriorating discharged patient, provision of opportunities for the patient to ask further questions and cultivation of good public relations.10 The importance of attaining outcome feedback has been acknowledged in the United States EM training programme. There is, however, persistent suboptimal compliance with this training requirement.10 One might expect, therefore, that in Australia and New Zealand, where there is less emphasis on outcome feedback, compliance with such practices will also be poor. In the Australasian setting, we propose that our training programme should actively encourage emergency clinicians to seek outcome feedback. We believe that seeking outcome feedback should become a training requirement. This could be supported by designated and protected time for trainees to read discharge summaries, follow-up investigation results and contact patients. To be able to improve our practice, it is crucial we are aware of the outcomes of our work. By making outcome feedback part of the regular workflow for emergency trainees (and Fellows), we might be able to disrupt, or at least circumvent, the feedback sanction.
Case 1 You review the notes a week later. The patient returned 4 days after her original presentation with persistent knee pain and a CT scan demonstrated a tibial plateau fracture. You check the initial X-ray and now notice a subtle fracture line.
Case 2 Who cares? It’s just a game, isn’t it?
Author contributions SG: concept, literature review, manuscript preparation; DE-W: concept, manuscript preparation; SC: literature review, manuscript preparation.
Competing interests DE-W is a section editor for Emergency Medicine Australasia.
References 1. Australian College of Emergency Medicine training manual. [Cited 12 Jul 2013.] Available from URL: http:// acem.org.au 2. Kuhn GJ. Diagnostic errors. Acad. Emerg. Med. 2002; 9: 740–50. 3. Schenkel SM, Khare RK, Rosenthal MM, Sutcliffe KM, Lewton EL. Resident perceptions of medical errors in the emergency department. Acad. Emerg. Med. 2003; 10: 1318–24. 4. Chern C-H, How C-K, Wang L-M, Lee C-H, Graff L. Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes. Ann. Emerg. Med. 2005; 45: 15–23. 5. Hobgood CD, Ma OJ, Swart GL. Emergency medicine resident errors identification and educational utilization. Acad. Emerg. Med. 2000; 7: 1317–20. 6. Croskerry P. The feedback sanction. Acad. Emerg. Med. 2000; 7: 1232–8. 7. Lavoie CF, Schachter H, Stewart AT, McGowan J. Does outcome feedback make you a better emergency physician? A systematic review and research framework proposal. CJEM 2009; 11: 545–52. 8. Lavoie CF, Plint AC, Clifford TJ, Gaboury I. ‘I never hear what happens, even if they die’: a survey of emergency physicians about outcome feedback. CJEM 2009; 11: 523–8. 9. Smith KA. To keep an incessant watch. Acad. Emerg. Med. 2011; 18: 545–8. 10. Gaeta TJ, Osborn HH. Increasing compliance with the residency review committee requirements for followup in academic emergency departments. Emergency Medicine Follow-up Study Group. Ann. Emerg. Med. 1999; 33: 510–5.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
